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Geanacopoulos AT, Amirault JP, Michelson KA, Monuteaux MC, Lipsett SC, Hirsch AW, Neuman MI. Community-Acquired Pneumonia Diagnosis Following Emergency Department Visits for Respiratory Illness. Clin Pediatr (Phila) 2024:99228241254153. [PMID: 38757645 DOI: 10.1177/00099228241254153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Community-acquired pneumonia (CAP) is often considered for children presenting to the emergency department (ED) with respiratory symptoms. It is unclear how often children are diagnosed with CAP following an ED visit for respiratory illness. We performed a retrospective case-control study to evaluate 7-day CAP diagnosis among children 3 months to 18 years discharged from the ED with respiratory illness from 2011 to 2021 and who receive care at 4 hospital-affiliated primary care clinics. Logistic regression was performed to assess for predictors of 7-day CAP diagnosis. Seventy-four (0.7%, 95% confidence interval [CI] = 0.6%, 0.9%) of 10 329 children were diagnosed with CAP within 7 days, and fever at the index visit was associated with increased odds of diagnosis (odds ratio [OR] = 3.32, 95% CI = 1.75-6.28). Community-acquired pneumonia diagnosis after discharge from the ED with respiratory illness is rare, even among children who are febrile at time of initial evaluation.
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Affiliation(s)
- Alexandra T Geanacopoulos
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Janine P Amirault
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Kenneth A Michelson
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael C Monuteaux
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Susan C Lipsett
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Alexander W Hirsch
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
| | - Mark I Neuman
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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Szymczak JE, Hayes AA, Labellarte P, Zighelboim J, Toor A, Becker AB, Gerber JS, Kuppermann N, Florin TA. Parent and Clinician Views on Not Using Antibiotics for Mild Community-Acquired Pneumonia. Pediatrics 2024; 153:e2023063782. [PMID: 38234215 DOI: 10.1542/peds.2023-063782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2023] [Indexed: 01/19/2024] Open
Abstract
OBJECTIVES Preschool-aged children with mild community-acquired pneumonia (CAP) routinely receive antibiotics even though most infections are viral. We sought to identify barriers to the implementation of a "no antibiotic" strategy for mild CAP in young children. METHODS Qualitative study using semistructured interviews conducted in a large pediatric hospital in the United States from January 2021 to July 2021. Parents of young children diagnosed with mild CAP in the previous 3 years and clinicians practicing in outpatient settings (pediatric emergency department, community emergency department, general pediatrics offices) were included. RESULTS Interviews were conducted with 38 respondents (18 parents, 20 clinicians). No parent heard of the no antibiotic strategy, and parents varied in their support for the approach. Degree of support related to their desire to avoid unnecessary medications, trust in clinicians, the emotional difficulty of caring for a sick child, desire for relief of suffering, willingness to accept the risk of unnecessary antibiotics, and judgment about the child's illness severity. Eleven (55%) clinicians were familiar with guidelines specifying a no antibiotic strategy. They identified challenges in not using antibiotics, including diagnostic uncertainty, consequences of undertreatment, parental expectations, follow-up concerns, and acceptance of the risks of unnecessary antibiotic treatment of many children if it means avoiding adverse outcomes for some children. CONCLUSIONS Although both parents and clinicians expressed broad support for the judicious use of antibiotics, pneumonia presents stewardship challenges. Interventions will need to consider the emotional, social, and logistical aspects of managing pneumonia, in addition to developing techniques to improve diagnosis.
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Affiliation(s)
- Julia E Szymczak
- Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Ashley A Hayes
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patricia Labellarte
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julian Zighelboim
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amandeep Toor
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Adam B Becker
- Smith Child Health Catalyst, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
| | - Todd A Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Rees CA, Kisenge R, Ideh RC, Kamara J, Coleman YJ, Samma A, Godfrey E, Manji HK, Sudfeld CR, Westbrook AL, Niescierenko M, Morris CR, Whitney CG, Breiman RF, Manji KP, Duggan CP. Predictive value of clinician impression for readmission and postdischarge mortality among neonates and young children in Dar es Salaam, Tanzania and Monrovia, Liberia. BMJ Paediatr Open 2023; 7:e001972. [PMID: 37385735 PMCID: PMC10314694 DOI: 10.1136/bmjpo-2023-001972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/11/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND There are no validated clinical decision aids to identify neonates and young children at risk of hospital readmission or postdischarge mortality in sub-Saharan Africa, leaving the decision to discharge a child to a clinician's impression. Our objective was to determine the precision of clinician impression to identify neonates and young children at risk for readmission and postdischarge mortality. METHODS We conducted a survey study nested in a prospective observational cohort of neonates and children aged 1-59 months followed 60 days after hospital discharge from Muhimbili National Hospital in Dar es Salaam, Tanzania or John F. Kennedy Medical Center in Monrovia, Liberia. Clinicians who discharged each enrolled patient were surveyed to determine their perceived probability of the patient's risk of 60-day hospital readmission or postdischarge mortality. We calculated the area under the precision-recall curve (AUPRC) to determine the precision of clinician impression for both outcomes. RESULTS Of 4247 discharged patients, 3896 (91.7%) had available clinician surveys and 3847 (98.7%) had 60-day outcomes available: 187 (4.8%) were readmitted and 120 (3.1%) died within 60 days of hospital discharge. Clinician impression had poor precision in identifying neonates and young children at risk of hospital readmission (AUPRC: 0.06, 95% CI: 0.04 to 0.08) and postdischarge mortality (AUPRC: 0.05, 95% CI: 0.03 to 0.08). Patients for whom clinicians attributed inability to pay for future medical treatment as the reason for risk for unplanned hospital readmission had 4.76 times the odds hospital readmission (95% CI: 1.31 to 17.25, p=0.02). CONCLUSIONS Given the poor precision of clinician impression alone to identify neonates and young children at risk of hospital readmission and postdischarge mortality, validated clinical decision aids are needed to aid in the identification of young children at risk for these outcomes.
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Affiliation(s)
- Chris A Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Readon C Ideh
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Julia Kamara
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Ye-Jeung Coleman
- Department of Pediatrics, John F. Kennedy Medical Center, Monrovia, Liberia
| | - Abraham Samma
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Evance Godfrey
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Hussein K Manji
- Department of Emergency Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
- Accident and Emergency Department, The Aga Khan Health Services, Dar es Salaam, United Republic of Tanzania
| | - Christopher R Sudfeld
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Adrianna L Westbrook
- Pediatric Biostatistics Core, Department of Pediatrics, Emory University, Atlanta, Georgia, USA
| | - Michelle Niescierenko
- Division of Emergency Medicine, Boston Children s Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Claudia R Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Cynthia G Whitney
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Robert F Breiman
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Karim P Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania
| | - Christopher P Duggan
- Departments of Nutrition and Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Center for Nutrition, Division of Gastroenterology, Hepatology, and Nutrition, Boston Children's Hospital, Boston, MA, USA
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Wang H, Li X, Zheng Y, Verhagen LM, Gu J, Li L, Xu Z, Wang W, de Jonge MI. Concordance in pathogen identification at the upper and lower respiratory tract of children with severe pneumonia. BMC Infect Dis 2023; 23:170. [PMID: 36941581 PMCID: PMC10026212 DOI: 10.1186/s12879-023-08127-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/28/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Nasopharyngeal swabs are taken to determine the causative agent of community acquired pneumonia (CAP), while the reliability of upper respiratory tract sampling as a proxy for lower respiratory tract infections is still unclear. METHODS Nasopharyngeal (NP) swabs, bronchoalveolar lavage (BAL) fluid samples and clinical data were collected from 153 hospitalized children between 3 months and 14 years of age with severe CAP, enrolled from March to June 2019. Written informed consent for the storage and use of the samples for further studies was obtained from the parents or caregivers. Putative pathogens were detected using a sensitive, high-throughput GeXP-based multiplex PCR and qPCR. RESULTS The same bacterial species in paired samples were found in 29 (23.4%) and the same viral species in 52 (27.5%) of the patients. moderate concordance was found for Mycoplasma pneumoniae (ĸ=0.64), followed by Haemophilus influenzae (ĸ=0.42). The strongest discordance was observed for human adenovirus and also for Pseudomonas aeruginosa, the latter was exclusively detected in BAL samples. In the adenovirus cases strong concordance was associated with high viral loads in the NP swabs. CONCLUSION The variation in concordance in pathogen detection in the upper and lower respiratory tract of children with severe pneumonia is generally high but varies depending on the species. Novel and impactful insights are the concordance between NP and BAL detection for M. pneumoniae and H. influenzae and the strong correlation between high adenoviral loads in NP swabs and detection in BAL fluid.
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Affiliation(s)
- Heping Wang
- Shenzhen Children's Hospital, No. 7019 Yitian Road, Futian District, Shenzhen, Guangdong, 518038, China
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, The Netherlands
| | - Xiaonan Li
- Shenzhen Children's Hospital, No. 7019 Yitian Road, Futian District, Shenzhen, Guangdong, 518038, China
| | - Yuejie Zheng
- Shenzhen Children's Hospital, No. 7019 Yitian Road, Futian District, Shenzhen, Guangdong, 518038, China
| | - Lilly M Verhagen
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, The Netherlands
- Department of Pediatric Infectious Diseases and Immunology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jiali Gu
- Shenzhen Children's Hospital, No. 7019 Yitian Road, Futian District, Shenzhen, Guangdong, 518038, China
| | - Li Li
- Shenzhen Children's Hospital, No. 7019 Yitian Road, Futian District, Shenzhen, Guangdong, 518038, China
| | - Zhi Xu
- Ningbo Health Gene Technologies Co., Ltd, Ningbo, Zhejiang, China
| | - Wenjian Wang
- Shenzhen Children's Hospital, No. 7019 Yitian Road, Futian District, Shenzhen, Guangdong, 518038, China.
| | - Marien I de Jonge
- Department of Laboratory Medicine, Laboratory of Medical Immunology, Radboud Center for Infectious Diseases, Radboud university medical center, Nijmegen, The Netherlands.
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Muljono MP, Halim G, Heriyanto RS, Meliani F, Budiputri CL, Vanessa MG, Andraina, Juliansen A, Octavius GS. Factors associated with severe childhood community-acquired pneumonia: a retrospective study from two hospitals. Egypt Pediatric Association Gaz 2022. [DOI: 10.1186/s43054-022-00123-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract
Background
Community-acquired pneumonia (CAP) is the leading cause of death in children globally. Indonesia is ranked 1st in South East Asia with the highest burden of pneumonia. Identification of risk factors is necessary for early intervention and better management. This study intended to describe CAP’s clinical signs and laboratory findings and explore the risk factors of severe CAP among children in Indonesia.
Methods
This was a retrospective study of childhood hospitalizations in Siloam General Hospitals and Siloam Hospitals Lippo Village from December 2015 to December 2019. Demographic data, clinical signs, and laboratory findings were collected and processed using IBM SPSS 26.0.
Results
This study included 217 participants with 66 (30.4%) severe pneumonia cases. Multivariate analysis shows that fever that lasts more than 7 days (ORadj = 4.95; 95%CI 1.61–15.21, Padj = 0.005) and increase in respiratory rate (ORadj = 1.05, 95%CI 1.01–1.08, Padj = 0.009) are two predictors of severe pneumonia. Meanwhile, a normal hematocrit level (ORadj = 0.9; 95%CI 0.83–0.98, Padj = 0.011) and children with normal BMI (ORadj = 0.7; 95%CI 0.57–0.84, Padj < 0.001) are significant independent predictors of severe pneumonia. The Hosmer-Lemeshow test shows that this model is a good fit with a P-value of 0.281. The AUC for this model is 0.819 (95%CI = 0.746–0.891, P-value < 0.001) which shows that this model has good discrimination.
Conclusion
Pediatric CAP hospitalizations with fever lasting > 7 days and tachypnea were at higher risk for progressing to severe pneumonia. A normal hematocrit level and a normal BMI are protective factors for severe pneumonia.
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Grossman D, Swaminathan A. Antibiotics for Pediatric Pneumonia: Might Less Be Enough? Ann Emerg Med 2022; 79:573-575. [DOI: 10.1016/j.annemergmed.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Koutroulis I, Velez T, Wang T, Yohannes S, Galarraga JE, Morales JA, Freishtat RJ, Chamberlain JM. Pediatric sepsis phenotypes for enhanced therapeutics: An application of clustering to electronic health records. J Am Coll Emerg Physicians Open 2022; 3:e12660. [PMID: 35112102 PMCID: PMC8790108 DOI: 10.1002/emp2.12660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/22/2021] [Accepted: 12/30/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The heterogeneity of pediatric sepsis patients suggests the potential benefits of clustering analytics to derive phenotypes with distinct host response patterns that may help guide personalized therapeutics. We evaluate the relative performance of latent class analysis (LCA) and K-means, 2 commonly used clustering methods toward the derivation of clinically useful pediatric sepsis phenotypes. METHODS Data were extracted from anonymized medical records of 6446 pediatric patients that presented to 1 of 6 emergency departments (EDs) between 2013 and 2018 and were thereafter admitted. Using International Classification of Diseases (ICD)-9 and ICD-10 discharge codes, 151 patients were identified with a sepsis continuum diagnosis that included septicemia, sepsis, severe sepsis, and septic shock. Using feature sets used in related clustering studies, LCA and K-means algorithms were used to derive 4 distinct phenotypic pediatric sepsis segmentations. Each segmentation was evaluated for phenotypic homogeneity, separation, and clinical use. RESULTS Using the 2 feature sets, LCA clustering resulted in 2 similar segmentations of 4 clinically distinct phenotypes, while K-means clustering resulted in segmentations of 3 and 4 phenotypes. All 4 segmentations identified at least 1 high severity phenotype, but LCA-identified phenotypes reflected superior stratification, high entropy approaching 1 (eg, 0.994) indicating excellent separation between estimated phenotypes, and differential treatment/treatment response, and outcomes that were non-randomly distributed across phenotypes (P < 0.001). CONCLUSION Compared to K-means, which is commonly used in clustering studies, LCA appears to be a more robust, clinically useful statistical tool in analyzing a heterogeneous pediatric sepsis cohort toward informing targeted therapies. Additional prospective studies are needed to validate clinical utility of predictive models that target derived pediatric sepsis phenotypes in emergency department settings.
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Affiliation(s)
- Ioannis Koutroulis
- Emergency MedicineChildren's National Hospital/George Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
| | - Tom Velez
- Computer Technology AssociatesCardiffCaliforniaUSA
| | | | | | | | | | - Robert J. Freishtat
- Emergency MedicineChildren's National Hospital/George Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
| | - James M. Chamberlain
- Emergency MedicineChildren's National Hospital/George Washington University School of Medicine and Health SciencesWashingtonDistrict of ColumbiaUSA
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Abstract
Abstract
Procalcitonin (PCT) is a useful, albeit imperfect, diagnostic aid that can help clinicians make more informed decisions around antibiotic use in children with lower respiratory tract infections (LRTI), including community-acquired pneumonia (CAP). Recent data suggest that a very low PCT concentration has a high negative predictive value to identify a population of children at low risk of typical bacterial infections. Although the preponderance of data on the clinical utility of PCT in LRTI come from adult studies, the potential for benefit is likely greatest in paediatric CAP and other LRTIs where viral aetiologies predominate, yet antibiotics are frequently prescribed.
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Affiliation(s)
- Todd A Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Division of Pediatric Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Derek J Williams
- Department of Pediatrics, Vanderbilt University School of Medicine and Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
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Scott KP, Lacy A, Freeman C, Barrett TW. Predicting Outcomes in Pediatric Pneumonia: Are We Omnipotent or Incompetent?: October 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 78:570-571. [PMID: 34563303 DOI: 10.1016/j.annemergmed.2021.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Kelly P Scott
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Aaron Lacy
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Clifford Freeman
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Tyler W Barrett
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
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Fatemi Y, Bell LM. Clinician Gestalt in Managing Pediatric Pneumonia: Can We Predict the Future? Pediatrics 2021; 147:peds.2020-048637. [PMID: 33903164 DOI: 10.1542/peds.2020-048637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Yasaman Fatemi
- Divisions of Infectious Diseases and.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Louis M Bell
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania .,General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
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