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Yates AR, Naim MY, Reeder RW, Ahmed T, Banks RK, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yeh J, Zuppa AF, Sutton RM, Meert KL. Early Cardiac Arrest Hemodynamics, End-Tidal C o2 , and Outcome in Pediatric Extracorporeal Cardiopulmonary Resuscitation: Secondary Analysis of the ICU-RESUScitation Project Dataset (2016-2021). Pediatr Crit Care Med 2024; 25:312-322. [PMID: 38088765 PMCID: PMC10994777 DOI: 10.1097/pcc.0000000000003423] [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] [Indexed: 12/30/2023]
Abstract
OBJECTIVES Cannulation for extracorporeal membrane oxygenation during active extracorporeal cardiopulmonary resuscitation (ECPR) is a method to rescue patients refractory to standard resuscitation. We hypothesized that early arrest hemodynamics and end-tidal C o2 (ET co2 ) are associated with survival to hospital discharge with favorable neurologic outcome in pediatric ECPR patients. DESIGN Preplanned, secondary analysis of pediatric Utstein, hemodynamic, and ventilatory data in ECPR patients collected during the 2016-2021 Improving Outcomes from Pediatric Cardiac Arrest study; the ICU-RESUScitation Project (ICU-RESUS; NCT02837497). SETTING Eighteen ICUs participated in ICU-RESUS. PATIENTS There were 97 ECPR patients with hemodynamic waveforms during cardiopulmonary resuscitation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall, 71 of 97 patients (73%) were younger than 1 year old, 82 of 97 (85%) had congenital heart disease, and 62 of 97 (64%) were postoperative cardiac surgical patients. Forty of 97 patients (41%) survived with favorable neurologic outcome. We failed to find differences in diastolic or systolic blood pressure, proportion achieving age-based target diastolic or systolic blood pressure, or chest compression rate during the initial 10 minutes of CPR between patients who survived with favorable neurologic outcome and those who did not. Thirty-five patients had ET co2 data; of 17 survivors with favorable neurologic outcome, four of 17 (24%) had an average ET co2 less than 10 mm Hg and two (12%) had a maximum ET co2 less than 10 mm Hg during the initial 10 minutes of resuscitation. CONCLUSIONS We did not identify an association between early hemodynamics achieved by high-quality CPR and survival to hospital discharge with favorable neurologic outcome after pediatric ECPR. Candidates for ECPR with ET co2 less than 10 mm Hg may survive with favorable neurologic outcome.
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Affiliation(s)
- Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Justin Yeh
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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2
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Cabler SS, Storch GA, Weinberg JB, Walton AH, Brengel-Pesce K, Aldewereld Z, Banks RK, Cheynet V, Reeder R, Holubkov R, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Cornell T, Harrison RE, Dean JM, Carcillo JA. Viral DNAemia and DNA Virus Seropositivity and Mortality in Pediatric Sepsis. JAMA Netw Open 2024; 7:e240383. [PMID: 38407904 PMCID: PMC10897747 DOI: 10.1001/jamanetworkopen.2024.0383] [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] [Received: 06/20/2023] [Accepted: 01/05/2024] [Indexed: 02/27/2024] Open
Abstract
Importance Sepsis is a leading cause of pediatric mortality. Little attention has been paid to the association between viral DNA and mortality in children and adolescents with sepsis. Objective To assess the association of the presence of viral DNA with sepsis-related mortality in a large multicenter study. Design, Setting, and Participants This cohort study compares pediatric patients with and without plasma cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus 1 (HSV-1), human herpesvirus 6 (HHV-6), parvovirus B19 (B19V), BK polyomavirus (BKPyV), human adenovirus (HAdV), and torque teno virus (TTV) DNAemia detected by quantitative real-time polymerase chain reaction or plasma IgG antibodies to CMV, EBV, HSV-1, or HHV-6. A total of 401 patients younger than 18 years with severe sepsis were enrolled from 9 pediatric intensive care units (PICUs) in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Collaborative Pediatric Critical Care Research Network. Data were collected from 2015 to 2018. Samples were assayed from 2019 to 2022. Data were analyzed from 2022 to 2023. Main Outcomes and Measures Death while in the PICU. Results Among the 401 patients included in the analysis, the median age was 6 (IQR, 1-12) years, and 222 (55.4%) were male. One hundred fifty-four patients (38.4%) were previously healthy, 108 (26.9%) were immunocompromised, and 225 (56.1%) had documented infection(s) at enrollment. Forty-four patients (11.0%) died in the PICU. Viral DNAemia with at least 1 virus (excluding TTV) was detected in 191 patients (47.6%) overall, 63 of 108 patients (58.3%) who were immunocompromised, and 128 of 293 (43.7%) who were not immunocompromised at sepsis onset. After adjustment for age, Pediatric Risk of Mortality score, previously healthy status, and immunocompromised status at sepsis onset, CMV (adjusted odds ratio [AOR], 3.01 [95% CI, 1.36-6.45]; P = .007), HAdV (AOR, 3.50 [95% CI, 1.46-8.09]; P = .006), BKPyV (AOR. 3.02 [95% CI, 1.17-7.34]; P = .02), and HHV-6 (AOR, 2.62 [95% CI, 1.31-5.20]; P = .007) DNAemia were each associated with increased mortality. Two or more viruses were detected in 78 patients (19.5%), with mortality among 12 of 32 (37.5%) who were immunocompromised and 9 of 46 (19.6%) who were not immunocompromised at sepsis onset. Herpesvirus seropositivity was common (HSV-1, 82 of 246 [33.3%]; CMV, 107 of 254 [42.1%]; EBV, 152 of 251 [60.6%]; HHV-6, 253 if 257 [98.4%]). After additional adjustment for receipt of blood products in the PICU, EBV seropositivity was associated with increased mortality (AOR, 6.10 [95% CI, 1.00-118.61]; P = .049). Conclusions and Relevance The findings of this cohort study suggest that DNAemia for CMV, HAdV, BKPyV, and HHV-6 and EBV seropositivity were independently associated with increased sepsis mortality. Further investigation of the underlying biology of these viral DNA infections in children with sepsis is warranted to determine whether they only reflect mortality risk or contribute to mortality.
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Affiliation(s)
- Stephanie S. Cabler
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Gregory A. Storch
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | | | - Andrew H. Walton
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | | | - Zachary Aldewereld
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | - Robert A. Berg
- Department of Anesthesiology, Pediatrics, University of Pennsylvania, Philadelphia
| | - David Wessel
- Department of Pediatrics, George Washington University, Washington, DC
| | - Murray M. Pollack
- Department of Pediatrics, George Washington University, Washington, DC
| | - Kathleen Meert
- Department of Pediatrics, Central Michigan University, Detroit
| | - Mark Hall
- Department of Pediatrics, The Ohio State University, Columbus
| | - Christopher Newth
- Department of Anesthesiology, University of Southern California, Los Angeles
| | - John C. Lin
- Department of Pediatrics, Washington University in St Louis, St Louis, Missouri
| | - Tim Cornell
- Department of Pediatrics, University of Michigan, Ann Arbor
| | | | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Joseph A. Carcillo
- Department of Pediatrics and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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3
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Zinna SS, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Cooper KK, Michael Dean J, Wesley Diddle J, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Hehir DA, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Chest compressions for pediatric organized rhythms: A hemodynamic and outcomes analysis. Resuscitation 2024; 194:110068. [PMID: 38052273 PMCID: PMC10843614 DOI: 10.1016/j.resuscitation.2023.110068] [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] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/16/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023]
Abstract
AIM Pediatric cardiopulmonary resuscitation (CPR) guidelines recommend starting CPR for heart rates (HRs) less than 60 beats per minute (bpm) with poor perfusion. Objectives were to (1) compare HRs and arterial blood pressures (BPs) prior to CPR among patients with clinician-reported bradycardia with poor perfusion ("BRADY") vs. pulseless electrical activity (PEA); and (2) determine if hemodynamics prior to CPR are associated with outcomes. METHODS AND RESULTS Prospective observational cohort study performed as a secondary analysis of the ICU-RESUScitation trial (NCT028374497). Comparisons occurred (1) during the 15 seconds "immediately" prior to CPR and (2) over the two minutes prior to CPR, stratified by age (≤1 year, >1 year). Poisson regression models assessed associations between hemodynamics and outcomes. Primary outcome was return of spontaneous circulation (ROSC). Pre-CPR HRs were lower in BRADY vs. PEA (≤1 year: 63.8 [46.5, 87.0] min-1 vs. 120 [93.2, 150.0], p < 0.001; >1 year: 67.4 [54.5, 87.0] min-1 vs. 100 [66.7, 120], p < 0.014). Pre-CPR pulse pressure was higher among BRADY vs. PEA (≤1 year (12.9 [9.0, 28.5] mmHg vs. 10.4 [6.1, 13.4] mmHg, p > 0.001). Pre-CPR pulse pressure ≥ 20 mmHg was associated with higher rates of ROSC among PEA (aRR 1.58 [CI95 1.07, 2.35], p = 0.022) and survival to hospital discharge with favorable neurologic outcome in both groups (BRADY: aRR 1.28 [CI95 1.01, 1.62], p = 0.040; PEA: aRR 1.94 [CI95 1.19, 3.16], p = 0.008). Pre-CPR HR ≥ 60 bpm was not associated with outcomes. CONCLUSIONS Pulse pressure and HR are used clinically to differentiate BRADY from PEA. A pre-CPR pulse pressure >20 mmHg was associated with improved patient outcomes.
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Affiliation(s)
- Shairbanu S Zinna
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kellimarie K Cooper
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
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4
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Federman M, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Kirkpatrick T, Maa T, Maitoza LA, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Naim MY. Survival With Favorable Neurologic Outcome and Quality of Cardiopulmonary Resuscitation Following In-Hospital Cardiac Arrest in Children With Cardiac Disease Compared With Noncardiac Disease. Pediatr Crit Care Med 2024; 25:4-14. [PMID: 37678381 PMCID: PMC10843749 DOI: 10.1097/pcc.0000000000003368] [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] [Indexed: 09/09/2023]
Abstract
OBJECTIVES To assess associations between outcome and cardiopulmonary resuscitation (CPR) quality for in-hospital cardiac arrest (IHCA) in children with medical cardiac, surgical cardiac, or noncardiac disease. DESIGN Secondary analysis of a multicenter cluster randomized trial, the ICU-RESUScitation Project (NCT02837497, 2016-2021). SETTING Eighteen PICUs. PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks postconceptual age receiving chest compressions (CC) of any duration during the study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 1,100 children with IHCA, there were 273 medical cardiac (25%), 383 surgical cardiac (35%), and 444 noncardiac (40%) cases. Favorable neurologic outcome was defined as no more than moderate disability or no worsening from baseline Pediatric Cerebral Performance Category at discharge. The medical cardiac group had lower odds of survival with favorable neurologic outcomes compared with the noncardiac group (48% vs 55%; adjusted odds ratio [aOR] [95% CI], aOR 0.59 [95% CI, 0.39-0.87], p = 0.008) and surgical cardiac group (48% vs 58%; aOR 0.64 [95% CI, 0.45-0.9], p = 0.01). We failed to identify a difference in favorable outcomes between surgical cardiac and noncardiac groups. We also failed to identify differences in CC rate, CC fraction, ventilation rate, intra-arrest average target diastolic or systolic blood pressure between medical cardiac versus noncardiac, and surgical cardiac versus noncardiac groups. The surgical cardiac group had lower odds of achieving target CC depth compared to the noncardiac group (OR 0.15 [95% CI, 0.02-0.52], p = 0.001). We failed to identify a difference in the percentage of patients achieving target CC depth when comparing medical cardiac versus noncardiac groups. CONCLUSIONS In pediatric IHCA, medical cardiac patients had lower odds of survival with favorable neurologic outcomes compared with noncardiac and surgical cardiac patients. We failed to find differences in CPR quality between medical cardiac and noncardiac patients, but there were lower odds of achieving target CC depth in surgical cardiac compared to noncardiac patients.
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Affiliation(s)
- Myke Federman
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children’s Hospital, Delaware, Wilmington, DE, USA
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, St. Louis, MO, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Theresa Kirkpatrick
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Laura A Maitoza
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Murray M Pollack
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children’s Hospital, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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VanBuren JM, Hall M, Zuppa AF, Mourani PM, Carcillo J, Dean JM, Watt K, Holubkov R. The Design of Nested Adaptive Clinical Trials of Multiple Organ Dysfunction Syndrome Children in a Single Study. Pediatr Crit Care Med 2023; 24:e635-e646. [PMID: 37498156 PMCID: PMC10817996 DOI: 10.1097/pcc.0000000000003332] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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] [Indexed: 07/28/2023]
Abstract
OBJECTIVES Describe the statistical design of the Personalized Immunomodulation in Sepsis-induced Multiple Organ Dysfunction Syndrome (MODS) (PRECISE) study. DESIGN Children with sepsis-induced MODS undergo real-time immune testing followed by assignment to an immunophenotype-specific study cohort. Interventional cohorts include the granulocyte macrophage-colony stimulating factor (GM-CSF) for the Reversal of Immunoparalysis in Pediatric Sepsis-induced MODS (GRACE)-2 trial, which uses the drug GM-CSF (or placebo) to reverse immunoparalysis; and the Targeted Reversal of Inflammation in Pediatric Sepsis-induced MODS (TRIPS) trial, which uses the drug anakinra (or placebo) to reverse systemic inflammation. Both trials have adaptive components and use a statistical framework in which frequent data monitoring assesses futility and efficacy, allowing potentially earlier stopping than traditional approaches. Prespecified simulation-based stopping boundaries are customized to each trial to preserve an overall one-sided type I error rate. The TRIPS trial also uses response-adaptive randomization, updating randomization allocation proportions to favor active arms that appear more efficacious based on accumulating data. SETTING Twenty-four U.S. academic PICUs. PATIENTS Septic children with specific immunologic derangements during ongoing dysfunction of at least two organs. INTERVENTIONS The GRACE-2 trial compares GM-CSF and placebo in children with immunoparalysis. The TRIPS trial compares four different doses of anakinra to placebo in children with moderate to severe systemic inflammation. MEASUREMENTS AND MAIN RESULTS Both trials assess primary efficacy using the sum of the daily pediatric logistic organ dysfunction-2 score over 28 days. Ranked summed scores, with mortality assigned the worst possible value, are compared between arms using the Wilcoxon Rank Sum test (GRACE-2) and a dose-response curve (TRIPS). We present simulation-based operating characteristics under several scenarios to demonstrate the behavior of the adaptive design. CONCLUSIONS The adaptive design incorporates innovative statistical features that allow for multiple active arms to be compared with placebo based on a child's personal immunophenotype. The design increases power and provides optimal operating characteristics compared with traditional conservative methods.
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Affiliation(s)
- John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Mark Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, Division of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR
| | - Joseph Carcillo
- Department of Critical Care Medicine and Pediatrics, University of Pittsburgh, Children's Hospital of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Kevin Watt
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
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6
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Podd BS, Banks RK, Reeder R, Telford R, Holubkov R, Carcillo J, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Randolph AG. Early, Persistent Lymphopenia Is Associated With Prolonged Multiple Organ Failure and Mortality in Septic Children. Crit Care Med 2023; 51:1766-1776. [PMID: 37462434 DOI: 10.1097/ccm.0000000000005993] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023]
Abstract
OBJECTIVES Sepsis-associated immune suppression correlates with poor outcomes. Adult trials are evaluating immune support therapies. Limited data exist to support consideration of immunomodulation in pediatric sepsis. We tested the hypothesis that early, persistent lymphopenia predicts worse outcomes in pediatric severe sepsis. DESIGN Observational cohort comparing children with severe sepsis and early, persistent lymphopenia (absolute lymphocyte count < 1,000 cells/µL on 2 d between study days 0-5) to children without. The composite outcome was prolonged multiple organ dysfunction syndrome (MODS, organ dysfunction beyond day 7) or PICU mortality. SETTING Nine PICUs in the National Institutes of Health Collaborative Pediatric Critical Care Research Network between 2015 and 2017. PATIENTS Children with severe sepsis and indwelling arterial and/or central venous catheters. INTERVENTIONS Blood sampling and clinical data analysis. MEASUREMENTS AND MAIN RESULTS Among 401 pediatric patients with severe sepsis, 152 (38%) had persistent lymphopenia. These patients were older, had higher illness severity, and were more likely to have underlying comorbidities including solid organ transplant or malignancy. Persistent lymphopenia was associated with the composite outcome prolonged MODS or PICU mortality (66/152, 43% vs 45/249, 18%; p < 0.01) and its components prolonged MODS (59/152 [39%] vs 43/249 [17%]), and PICU mortality (32/152, 21% vs 12/249, 5%; p < 0.01) versus children without. After adjusting for baseline factors at enrollment, the presence of persistent lymphopenia was associated with an odds ratio of 2.98 (95% CI [1.85-4.02]; p < 0.01) for the composite outcome. Lymphocyte count trajectories showed that patients with persistent lymphopenia generally did not recover lymphocyte counts during the study, had lower nadir whole blood tumor necrosis factor-α response to lipopolysaccharide stimulation, and higher maximal inflammatory markers (C-reactive protein and ferritin) during days 0-3 ( p < 0.01). CONCLUSIONS Children with severe sepsis and persistent lymphopenia are at risk of prolonged MODS or PICU mortality. This evidence supports testing therapies for pediatric severe sepsis patients risk-stratified by early, persistent lymphopenia.
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Affiliation(s)
- Bradley S Podd
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Russell K Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Russell Telford
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Joseph Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Pittsburgh, PA
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA
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7
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Palm ME, Thompson DD, Edwards T, Swartz K, Herzog KA, Bansal S, Echalier B, DeHart KC, Denmark S, Wilson JL, Nelson S, Waddy SP, Dunsmore SE, Atkinson JC, Wiley K, Hassani S, Dwyer JP, Hanley DF, Dean JM, Ford DE. The Trial Innovation Network Liaison Team: building a national clinical and translational community of practice. J Clin Transl Sci 2023; 7:e249. [PMID: 38229890 PMCID: PMC10790104 DOI: 10.1017/cts.2023.675] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 10/19/2023] [Accepted: 10/20/2023] [Indexed: 01/18/2024] Open
Abstract
In 2016, the National Center for Advancing Translational Science launched the Trial Innovation Network (TIN) to address barriers to efficient and informative multicenter trials. The TIN provides a national platform, working in partnership with 60+ Clinical and Translational Science Award (CTSA) hubs across the country to support the design and conduct of successful multicenter trials. A dedicated Hub Liaison Team (HLT) was established within each CTSA to facilitate connection between the hubs and the newly launched Trial and Recruitment Innovation Centers. Each HLT serves as an expert intermediary, connecting CTSA Hub investigators with TIN support, and connecting TIN research teams with potential multicenter trial site investigators. The cross-consortium Liaison Team network was developed during the first TIN funding cycle, and it is now a mature national network at the cutting edge of team science in clinical and translational research. The CTSA-based HLT structures and the external network structure have been developed in collaborative and iterative ways, with methods for shared learning and continuous process improvement. In this paper, we review the structure, function, and development of the Liaison Team network, discuss lessons learned during the first TIN funding cycle, and outline a path toward further network maturity.
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Affiliation(s)
- Marisha E. Palm
- Tufts Medical Center, Boston, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Dixie D. Thompson
- Clinical & Translational Science Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Terri Edwards
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kitt Swartz
- Oregon Clinical and Translational Research Institute, Oregon Health & Science University, Portland, OR, USA
| | - Keith A. Herzog
- Northwestern University Clinical and Translational Science Institute, Chicago, IL, USA
| | - Shweta Bansal
- University of Texas Health Science Center, San Antonio, TX, USA
| | | | | | - Signe Denmark
- Medical University of South Carolina, Charleston, SC, USA
| | - Jurran L. Wilson
- Clinical and Translational Science Institute at Children’s National Hospital, Children’s National Hospital, Washington, DC, USA
| | - Sarah Nelson
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Salina P. Waddy
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Sarah E. Dunsmore
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Jane C. Atkinson
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Ken Wiley
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Sara Hassani
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Jamie P. Dwyer
- Clinical & Translational Science Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel F. Hanley
- Acute Care Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J. Michael Dean
- Clinical & Translational Science Institute, University of Utah School of Medicine, Salt Lake City, UT, USA
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel E. Ford
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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8
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Palm ME, Edwards TL, Wieber C, Kay MT, Marion E, Boone L, Nanni A, Jones M, Pham E, Hildreth M, Lane K, McBee N, Benjamin DK, Bernard GR, Dean JM, Dwyer JP, Ford DE, Hanley DF, Harris PA, Wilkins CH, Selker HP. Development, implementation, and dissemination of operational innovations across the trial innovation network. J Clin Transl Sci 2023; 7:e251. [PMID: 38229905 PMCID: PMC10790103 DOI: 10.1017/cts.2023.658] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/13/2023] [Accepted: 10/14/2023] [Indexed: 01/18/2024] Open
Abstract
Improving the quality and conduct of multi-center clinical trials is essential to the generation of generalizable knowledge about the safety and efficacy of healthcare treatments. Despite significant effort and expense, many clinical trials are unsuccessful. The National Center for Advancing Translational Science launched the Trial Innovation Network to address critical roadblocks in multi-center trials by leveraging existing infrastructure and developing operational innovations. We provide an overview of the roadblocks that led to opportunities for operational innovation, our work to develop, define, and map innovations across the network, and how we implemented and disseminated mature innovations.
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Affiliation(s)
- Marisha E. Palm
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Terri L. Edwards
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cortney Wieber
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
| | - Marie T. Kay
- University of Utah Health, Salt Lake City, UT, USA
| | - Eve Marion
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Leslie Boone
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Angeline Nanni
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michelle Jones
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eilene Pham
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Meghan Hildreth
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nichol McBee
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jamie P. Dwyer
- University of Utah Health, Salt Lake City, UT, USA
- Utah Clinical and Translational Sciences Institute, Salt Lake City, UT, USA
| | - Daniel E. Ford
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel F. Hanley
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul A. Harris
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Biomedical Informatics, Biostatistics, and Biomedical Engineering, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Consuelo H. Wilkins
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Harry P. Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
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9
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Gardner MM, Hehir DA, Reeder RW, Ahmed T, Bell MJ, Berg RA, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Harding ML, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Topjian AA. Identification of post-cardiac arrest blood pressure thresholds associated with outcomes in children: an ICU-Resuscitation study. Crit Care 2023; 27:388. [PMID: 37805481 PMCID: PMC10559632 DOI: 10.1186/s13054-023-04662-9] [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] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 09/26/2023] [Indexed: 10/09/2023] Open
Abstract
INTRODUCTION Though early hypotension after pediatric in-hospital cardiac arrest (IHCA) is associated with inferior outcomes, ideal post-arrest blood pressure (BP) targets have not been established. We aimed to leverage prospectively collected BP data to explore the association of post-arrest BP thresholds with outcomes. We hypothesized that post-arrest systolic and diastolic BP thresholds would be higher than the currently recommended post-cardiopulmonary resuscitation BP targets and would be associated with higher rates of survival to hospital discharge. METHODS We performed a secondary analysis of prospectively collected BP data from the first 24 h following return of circulation from index IHCA events enrolled in the ICU-RESUScitation trial (NCT02837497). The lowest documented systolic BP (SBP) and diastolic BP (DBP) were percentile-adjusted for age, height and sex. Receiver operator characteristic curves and cubic spline analyses controlling for illness category and presence of pre-arrest hypotension were generated exploring the association of lowest post-arrest SBP and DBP with survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category of 1-3 or no change from baseline). Optimal cutoffs for post-arrest BP thresholds were based on analysis of receiver operator characteristic curves and spline curves. Logistic regression models accounting for illness category and pre-arrest hypotension examined the associations of these thresholds with outcomes. RESULTS Among 693 index events with 0-6 h post-arrest BP data, identified thresholds were: SBP > 10th percentile and DBP > 50th percentile for age, sex and height. Fifty-one percent (n = 352) of subjects had lowest SBP above threshold and 50% (n = 346) had lowest DBP above threshold. SBP and DBP above thresholds were each associated with survival to hospital discharge (SBP: aRR 1.21 [95% CI 1.10, 1.33]; DBP: aRR 1.23 [1.12, 1.34]) and survival to hospital discharge with favorable neurologic outcome (SBP: aRR 1.22 [1.10, 1.35]; DBP: aRR 1.27 [1.15, 1.40]) (all p < 0.001). CONCLUSIONS Following pediatric IHCA, subjects had higher rates of survival to hospital discharge and survival to hospital discharge with favorable neurologic outcome when BP targets above a threshold of SBP > 10th percentile for age and DBP > 50th percentile for age during the first 6 h post-arrest.
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Affiliation(s)
- Monique M Gardner
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Monica L Harding
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Alexis A Topjian
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
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10
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Harris PA, Dunsmore SE, Atkinson JC, Benjamin DK, Bernard GR, Dean JM, Dwyer JP, Ford DF, Selker HP, Waddy SP, Wiley KL, Wilkins CH, Cook SK, Burr JS, Edwards TL, Huvane J, Kennedy N, Lane K, Majkowski R, Nelson S, Palm ME, Stroud M, Thompson DD, Busacca L, Elkind MSV, Kimberly RP, Reilly MP, Hanley DF. Leveraging the Expertise of the CTSA Program to Increase the Impact and Efficiency of Clinical Trials. JAMA Netw Open 2023; 6:e2336470. [PMID: 37796498 PMCID: PMC10773966 DOI: 10.1001/jamanetworkopen.2023.36470] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
Importance Multicenter clinical trials play a critical role in the translational processes that enable new treatments to reach all people and improve public health. However, conducting multicenter randomized clinical trials (mRCT) presents challenges. The Trial Innovation Network (TIN), established in 2016 to partner with the Clinical and Translational Science Award (CTSA) Consortium of academic medical institutions in the implementation of mRCTs, consists of 3 Trial Innovation Centers (TICs) and 1 Recruitment Innovation Center (RIC). This unique partnership has aimed to address critical roadblocks that impede the design and conduct of mRCTs, in expectation of accelerating the translation of novel interventions to clinical practice. The TIN's challenges and achievements are described in this article, along with examples of innovative resources and processes that may serve as useful models for other clinical trial networks providing operational and recruitment support. Observations The TIN has successfully integrated more than 60 CTSA institution program hubs into a functional network for mRCT implementation and optimization. A unique support system for investigators has been created that includes the development and deployment of novel tools, operational and recruitment services, consultation models, and rapid communication pathways designed to reduce delays in trial start-up, enhance recruitment, improve engagement of diverse research participants and communities, and streamline processes that improve the quality, efficiency, and conduct of mRCTs. These resources and processes span the clinical trial spectrum and enable the TICs and RIC to serve as coordinating centers, data centers, and recruitment specialists to assist trials across the National Institutes of Health and other agencies. The TIN's impact has been demonstrated through its response to both historical operational challenges and emerging public health emergencies, including the national opioid public health crisis and the COVID-19 pandemic. Conclusions and Relevance The TIN has worked to reduce barriers to implementing mRCTs and to improve mRCT processes and operations by providing needed clinical trial infrastructure and resources to CTSA investigators. These resources have been instrumental in more quickly and efficiently translating research discoveries into beneficial patient treatments.
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Affiliation(s)
- Paul A Harris
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah E Dunsmore
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Jane C Atkinson
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Daniel Kelly Benjamin
- Duke University School of Medicine, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Gordon R Bernard
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jamie P Dwyer
- University of Utah Health, Salt Lake City
- Utah Clinical and Translational Sciences Institute, Salt Lake City
| | - Daniel F Ford
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, Maryland
| | - Harry P Selker
- Department of Medicine, Tufts University, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Salina P Waddy
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Kenneth L Wiley
- National Center for Advancing Translational Sciences, Bethesda, Maryland
| | - Consuelo H Wilkins
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Internal Medicine, Meharry Medical College, Nashville, Tennessee
| | - Sarah K Cook
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
| | | | - Terri L Edwards
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
| | | | - Nan Kennedy
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
| | - Karen Lane
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ryan Majkowski
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sarah Nelson
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
| | - Marisha E Palm
- Department of Medicine, Tufts University, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
| | - Mary Stroud
- Vanderbilt Institute for Clinical and Translational Research, Nashville, Tennessee
| | - Dixie D Thompson
- University of Utah Health, Salt Lake City
- Utah Clinical and Translational Sciences Institute, Salt Lake City
| | - Linda Busacca
- Irving Institute for Clinical and Translational Research, Columbia University Irving Medical Center, New York, New York
| | - Mitchell S V Elkind
- Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, New York, New York
| | - Robert P Kimberly
- Center for Clinical and Translational Science, University of Alabama at Birmingham
| | - Muredach P Reilly
- Irving Institute for Clinical and Translational Research, Columbia University Irving Medical Center, New York, New York
| | - Daniel F Hanley
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, Maryland
- Johns Hopkins University School of Medicine, Baltimore, Maryland
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11
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Fan Z, Kernan KF, Qin Y, Canna S, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Sward K, Dean JM, Park HJ, Carcillo JA. Hyperferritinemic sepsis, macrophage activation syndrome, and mortality in a pediatric research network: a causal inference analysis. Crit Care 2023; 27:347. [PMID: 37674218 PMCID: PMC10481565 DOI: 10.1186/s13054-023-04628-x] [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] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND One of five global deaths are attributable to sepsis. Hyperferritinemic sepsis (> 500 ng/mL) is associated with increased mortality in single-center studies. Our pediatric research network's objective was to obtain rationale for designing anti-inflammatory clinical trials targeting hyperferritinemic sepsis. METHODS We assessed differences in 32 cytokines, immune depression (low whole blood ex vivo TNF response to endotoxin) and thrombotic microangiopathy (low ADAMTS13 activity) biomarkers, seven viral DNAemias, and macrophage activation syndrome (MAS) defined by combined hepatobiliary dysfunction and disseminated intravascular coagulation, and mortality in 117 children with hyperferritinemic sepsis (ferritin level > 500 ng/mL) compared to 280 children with sepsis without hyperferritinemia. Causal inference analysis of these 41 variables, MAS, and mortality was performed. RESULTS Mortality was increased in children with hyperferritinemic sepsis (27/117, 23% vs 16/280, 5.7%; Odds Ratio = 4.85, 95% CI [2.55-9.60]; z = 4.728; P-value < 0.0001). Hyperferritinemic sepsis had higher C-reactive protein, sCD163, IL-22, IL-18, IL-18 binding protein, MIG/CXCL9, IL-1β, IL-6, IL-8, IL-10, IL-17a, IFN-γ, IP10/CXCL10, MCP-1/CCL2, MIP-1α, MIP-1β, TNF, MCP-3, IL-2RA (sCD25), IL-16, M-CSF, and SCF levels; lower ADAMTS13 activity, sFasL, whole blood ex vivo TNF response to endotoxin, and TRAIL levels; more Adenovirus, BK virus, and multiple virus DNAemias; and more MAS (P-value < 0.05). Among these variables, only MCP-1/CCL2 (the monocyte chemoattractant protein), MAS, and ferritin levels were directly causally associated with mortality. MCP-1/CCL2 and hyperferritinemia showed direct causal association with depressed ex vivo whole blood TNF response to endotoxin. MCP-1/CCL2 was a mediator of MAS. MCP-1/CCL2 and MAS were mediators of hyperferritinemia. CONCLUSIONS These findings establish hyperferritinemic sepsis as a high-risk condition characterized by increased cytokinemia, viral DNAemia, thrombotic microangiopathy, immune depression, macrophage activation syndrome, and death. The causal analysis provides rationale for designing anti-inflammatory trials that reduce macrophage activation to improve survival and enhance infection clearance in pediatric hyperferritinemic sepsis.
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Affiliation(s)
- Zhenziang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Faculty Pavilion, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Yidi Qin
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott Canna
- Department of Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Katherine Sward
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - H J Park
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Faculty Pavilion, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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12
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Morgan RW, Reeder RW, Ahmed T, Bell MJ, Berger JT, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Himebauch AS, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Berg RA, Sutton RM. Outcomes and characteristics of cardiac arrest in children with pulmonary hypertension: A secondary analysis of the ICU-RESUS clinical trial. Resuscitation 2023; 190:109897. [PMID: 37406760 PMCID: PMC10530491 DOI: 10.1016/j.resuscitation.2023.109897] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/09/2023] [Accepted: 06/27/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND Previous studies have identified pulmonary hypertension (PH) as a relatively common diagnosis in children with in-hospital cardiac arrest (IHCA), and preclinical laboratory studies have found poor outcomes and low systemic blood pressures during CPR for PH-associated cardiac arrest. The objective of this study was to determine the prevalence of PH among children with IHCA and the association between PH diagnosis and intra-arrest physiology and survival outcomes. METHODS This was a prospectively designed secondary analysis of patients enrolled in the ICU-RESUS clinical trial (NCT02837497). The primary exposure was a pre-arrest diagnosis of PH. The primary survival outcome was survival to hospital discharge with favorable neurologic outcome (Pediatric Cerebral Performance Category score 1-3 or unchanged from baseline). The primary physiologic outcome was event-level average diastolic blood pressure (DBP) during CPR. RESULTS Of 1276 patients with IHCAs during the study period, 1129 index IHCAs were enrolled; 184 (16.3%) had PH and 101/184 (54.9%) were receiving inhaled nitric oxide at the time of IHCA. Survival with favorable neurologic outcome was similar between patients with and without PH on univariate (48.9% vs. 54.4%; p = 0.17) and multivariate analyses (aOR 0.82 [95%CI: 0.56, 1.20]; p = 0.32). There were no significant differences in CPR event outcome or survival to hospital discharge. Average DBP, systolic BP, and end-tidal carbon dioxide during CPR were similar between groups. CONCLUSIONS In this prospective study of pediatric IHCA, pre-existing PH was present in 16% of children. Pre-arrest PH diagnosis was not associated with statistically significant differences in survival outcomes or intra-arrest physiologic measures.
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Affiliation(s)
- Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA.
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - John T Berger
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Aisha H Frazier
- Nemours Cardiac Center, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA; Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Adam S Himebauch
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Shirley Viteri
- Department of Pediatrics, Nemours Children's Health, Delaware and Thomas Jefferson University, Wilmington, DE, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA, USA
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13
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Hanley DF, Bernard GR, Wilkins CH, Selker HP, Dwyer JP, Dean JM, Benjamin DK, Dunsmore SE, Waddy SP, Wiley KL, Palm ME, Mould WA, Ford DF, Burr JS, Huvane J, Lane K, Poole L, Edwards TL, Kennedy N, Boone LR, Bell J, Serdoz E, Byrne LM, Harris PA. Decentralized clinical trials in the trial innovation network: Value, strategies, and lessons learned. J Clin Transl Sci 2023; 7:e170. [PMID: 37654775 PMCID: PMC10465321 DOI: 10.1017/cts.2023.597] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/13/2023] [Indexed: 09/02/2023] Open
Abstract
New technologies and disruptions related to Coronavirus disease-2019 have led to expansion of decentralized approaches to clinical trials. Remote tools and methods hold promise for increasing trial efficiency and reducing burdens and barriers by facilitating participation outside of traditional clinical settings and taking studies directly to participants. The Trial Innovation Network, established in 2016 by the National Center for Advancing Clinical and Translational Science to address critical roadblocks in clinical research and accelerate the translational research process, has consulted on over 400 research study proposals to date. Its recommendations for decentralized approaches have included eConsent, participant-informed study design, remote intervention, study task reminders, social media recruitment, and return of results for participants. Some clinical trial elements have worked well when decentralized, while others, including remote recruitment and patient monitoring, need further refinement and assessment to determine their value. Partially decentralized, or "hybrid" trials, offer a first step to optimizing remote methods. Decentralized processes demonstrate potential to improve urban-rural diversity, but their impact on inclusion of racially and ethnically marginalized populations requires further study. To optimize inclusive participation in decentralized clinical trials, efforts must be made to build trust among marginalized communities, and to ensure access to remote technology.
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Affiliation(s)
- Daniel F. Hanley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, MD, USA
| | - Gordon R. Bernard
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Consuelo H. Wilkins
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
- Department of Internal Medicine, Meharry Medical College, Nashville, TN, USA
| | - Harry P. Selker
- Department of Medicine, Tufts University, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Jamie P. Dwyer
- University of Utah Health, Salt Lake City, UT, USA
- Utah Clinical and Translational Sciences Institute, Salt Lake City, UT, USA
| | | | - Daniel Kelly Benjamin
- Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Sarah E. Dunsmore
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Salina P. Waddy
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Kenneth L. Wiley
- National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Marisha E. Palm
- Department of Medicine, Tufts University, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - W. Andrew Mould
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins BIOS Clinical Trials Coordinating Center, Baltimore, MD, USA
| | - Daniel F. Ford
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, MD, USA
| | - Jeri S. Burr
- University of Utah Health, Salt Lake City, UT, USA
| | | | - Karen Lane
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Institute for Clinical and Translational Research, Baltimore, MD, USA
| | - Lori Poole
- Duke Clinical Research Institute, Durham, NC, USA
| | - Terri L. Edwards
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Nan Kennedy
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Leslie R. Boone
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Jasmine Bell
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Emily Serdoz
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Loretta M. Byrne
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | - Paul A. Harris
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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14
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Lane K, Palm ME, Marion E, Kay MT, Thompson D, Stroud M, Boyle H, Hillery S, Nanni A, Hildreth M, Nelson S, Burr JS, Edwards T, Poole L, Waddy SP, Dunsmore SE, Harris P, Wilkins C, Bernard GR, Dean JM, Dwyer J, Benjamin DK, Selker HP, Hanley DF, Ford DE. Approaches for enhancing the informativeness and quality of clinical trials: Innovations and principles for implementing multicenter trials from the Trial Innovation Network. J Clin Transl Sci 2023; 7:e131. [PMID: 37396815 PMCID: PMC10308427 DOI: 10.1017/cts.2023.560] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 05/04/2023] [Accepted: 05/16/2023] [Indexed: 07/04/2023] Open
Abstract
One challenge for multisite clinical trials is ensuring that the conditions of an informative trial are incorporated into all aspects of trial planning and execution. The multicenter model can provide the potential for a more informative environment, but it can also place a trial at risk of becoming uninformative due to lack of rigor, quality control, or effective recruitment, resulting in premature discontinuation and/or non-publication. Key factors that support informativeness are having the right team and resources during study planning and implementation and adequate funding to support performance activities. This communication draws on the experience of the National Center for Advancing Translational Science (NCATS) Trial Innovation Network (TIN) to develop approaches for enhancing the informativeness of clinical trials. We distilled this information into three principles: (1) assemble a diverse team, (2) leverage existing processes and systems, and (3) carefully consider budgets and contracts. The TIN, comprised of NCATS, three Trial Innovation Centers, a Recruitment Innovation Center, and 60+ CTSA Program hubs, provides resources to investigators who are proposing multicenter collaborations. In addition to sharing principles that support the informativeness of clinical trials, we highlight TIN-developed resources relevant for multicenter trial initiation and conduct.
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Affiliation(s)
- Karen Lane
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marisha E. Palm
- Tufts Medical Center, Boston, MA, USA
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Eve Marion
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Marie T. Kay
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Dixie Thompson
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Mary Stroud
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Helen Boyle
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Shannon Hillery
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Angeline Nanni
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Meghan Hildreth
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sarah Nelson
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jeri S. Burr
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Terri Edwards
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lori Poole
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Salina P. Waddy
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Sarah E. Dunsmore
- Division of Clinical Innovation, National Center for Advancing Translational Sciences, Bethesda, MD, USA
| | - Paul Harris
- Vanderbilt School of Medicine, Nashville, TN, USA
| | - Consuelo Wilkins
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - J. Michael Dean
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jamie Dwyer
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Harry P. Selker
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, MA, USA
- Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Daniel F. Hanley
- Acute Care Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel E. Ford
- Institute for Clinical and Translational Research, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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Cashen K, Sutton RM, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Michael Dean J, Wesley Diddle J, Federman M, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, KirkpatrickN T, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Page K, Pollack MM, Qunibi D, Sapru A, Schneiter C, Sharron MP, Srivastava N, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Meert KL. Calcium use during paediatric in-hospital cardiac arrest is associated with worse outcomes. Resuscitation 2023; 185:109673. [PMID: 36565948 PMCID: PMC10065910 DOI: 10.1016/j.resuscitation.2022.109673] [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] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022]
Abstract
AIM To evaluate associations between calcium administration and outcomes among children with in-hospital cardiac arrest and among specific subgroups in which calcium use is hypothesized to provide clinical benefit. METHODS This is a secondary analysis of observational data collected prospectively as part of the ICU-RESUScitation project. Children 37 weeks post-conceptual age to 18 years who received chest compressions in one of 18 intensive care units from October 2016-March 2021 were eligible. Data included child and event characteristics, pre-arrest laboratory values, pre- and intra-arrest haemodynamics, and outcomes. Outcomes included sustained return of spontaneous circulation (ROSC), survival to hospital discharge, and survival to hospital discharge with favourable neurologic outcome. A propensity score weighted cohort was used to evaluate associations between calcium use and outcomes. Subgroups included neonates, and children with hyperkalaemia, sepsis, renal insufficiency, cardiac surgery with cardiopulmonary bypass, and calcium-avid cardiac diagnoses. RESULTS Of 1,100 in-hospital cardiac arrests, median age was 0.63 years (IQR 0.19, 3.81); 450 (41%) received calcium. Among the weighted cohort, calcium use was not associated with sustained ROSC (aOR, 0.87; CI95 0.61-1.24; p = 0.445), but was associated with lower rates of both survival to hospital discharge (aOR, 0.68; CI95 0.52-0.89; p = 0.005) and survival with favourable neurologic outcome at hospital discharge (aOR, 0.75; CI95 0.57-0.98; p = 0.038). Among subgroups, calcium use was associated with lower rates of survival to hospital discharge in children with sepsis and renal insufficiency. CONCLUSIONS Calcium use was common during paediatric in-hospital cardiac arrest and associated with worse outcomes at hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, 2301 Erwin Road, Durham, NC 27710, USA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, 100 Michigan St, NE, Grand Rapids, MI 49503, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Aisha H Frazier
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - Stuart H Friess
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA 15224, USA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Theresa KirkpatrickN
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Arushi Manga
- Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, One Children's Place, St. Louis, MO 63110, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California-San Francisco, 1845 Fourth Street, San Francisco, CA 94158, USA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Peter M Mourani
- Department of Pediatrics, University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, 13 Children's Way, Little Rock, AR 72202, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, 119 Lewis Thomas Laboratory, Washington Road, Princeton, NJ 08544, USA
| | - Kent Page
- Department of Pediatrics, University of Utah, 295 Chipeta Way, P.O. Box 581289, Salt Lake City, UT 84158, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Danna Qunibi
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Carleen Schneiter
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, 13121 East 17th Ave, Aurora, CO 80045, USA
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, 757 Westwood Plaza, Los Angeles, CA 90095, USA
| | - Shirley Viteri
- Nemours Children's Hospital, Delaware, 1600 Rockland Rd, Wilmington, DE, 19803, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, 1025 Walnut Street, Philadelphia, PA 19107, USA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, 700 Children's Drive, Columbus, OH 43205, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, 34th Street and Civic Center Blvd, Philadelphia, PA 19104, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, 3901 Beaubien Blvd, Detroit, MI 48201, USA.
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16
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Spivak AM, Barney BJ, Greene T, Holubkov R, Olsen CS, Bridges J, Srivastava R, Webb B, Sebahar F, Huffman A, Pacchia CF, Dean JM, Hess R. A Randomized Clinical Trial Testing Hydroxychloroquine for Reduction of SARS-CoV-2 Viral Shedding and Hospitalization in Early Outpatient COVID-19 Infection. Microbiol Spectr 2023; 11:e0467422. [PMID: 36861976 PMCID: PMC10101001 DOI: 10.1128/spectrum.04674-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 02/10/2023] [Indexed: 03/03/2023] Open
Abstract
Early in the COVID-19 pandemic, no effective treatment existed to prevent clinical worsening of COVID-19 among recently diagnosed outpatients. At the University of Utah, Salt Lake City, Utah, we conducted a phase 2 prospective parallel group randomized placebo-controlled trial (NCT04342169) to determine whether hydroxychloroquine given early in disease reduces the duration of SARS-CoV-2 shedding. We enrolled nonhospitalized adults (≥18 years of age) with a recent positive diagnostic test for SARS-CoV-2 (within 72 h of enrollment) and adult household contacts. Participants received either 400 mg hydroxychloroquine by mouth twice daily on day 1 followed by 200 mg by mouth twice daily on days 2 to 5 or oral placebo with the same schedule. We performed SARS-CoV-2 nucleic acid amplification testing (NAAT) on oropharyngeal swabs on days 1 to 14 and 28 and monitored clinical symptomatology, rates of hospitalization, and viral acquisition by adult household contacts. We identified no overall differences in the duration of oropharyngeal carriage of SARS-CoV-2 (hazard ratio of viral shedding time comparing hydroxychloroquine to placebo, 1.21; 95% confidence interval [CI], 0.91, 1.62). Overall, 28-day hospitalization incidence was similar between treatments (4.6% hydroxychloroquine versus 2.7% placebo). No differences were seen in symptom duration, severity, or viral acquisition in household contacts between treatment groups. The study did not reach the prespecified enrollment target, which was likely influenced by a steep decline in COVID-19 incidence corresponding to the initial vaccine rollout in the spring of 2021. Oropharyngeal swabs were self-collected, which may introduce variability in these results. Placebo treatments were not identical to hydroxychloroquine treatments (capsules versus tablets) which may have led to inadvertent participant unblinding. In this group of community adults early in the COVID-19 pandemic, hydroxychloroquine did not significantly alter the natural history of early COVID-19 disease. (This study has been registered at ClinicalTrials.gov under registration no. NCT04342169). IMPORTANCE Early in the COVID-19 pandemic, no effective treatment existed to prevent clinical worsening of COVID-19 among recently diagnosed outpatients. Hydroxychloroquine received attention as a possible early treatment; however, quality prospective studies were lacking. We conducted a clinical trial to test the ability of hydroxychloroquine to prevent clinical worsening of COVID-19.
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Affiliation(s)
- Adam M. Spivak
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Bradley J. Barney
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Tom Greene
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Jordan Bridges
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Raj Srivastava
- Senior Medical Executive Director, Intermountain Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Brandon Webb
- Division of Infectious Diseases, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Frances Sebahar
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Ainsley Huffman
- Utah Clinical and Translational Science Institute, University of Utah, Salt Lake City, Utah, USA
| | | | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Rachel Hess
- Department of Medicine, University of Utah, Salt Lake City, Utah, USA
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
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17
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Bailly DK, Reeder RW, Muszynski JA, Meert KL, Ankola AA, Alexander PM, Pollack MM, Moler FW, Berg RA, Carcillo J, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Dalton H, Zuppa AF. Anticoagulation practices associated with bleeding and thrombosis in pediatric extracorporeal membrane oxygenation; a multi-center secondary analysis. Perfusion 2023; 38:363-372. [PMID: 35220828 DOI: 10.1177/02676591211056562] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
To determine associations between anticoagulation practices and bleeding and thrombosis during pediatric extracorporeal membrane oxygenation (ECMO), we performed a secondary analysis of prospectively collected data which included 481 children (<19 years), between January 2012 and September 2014. The primary outcome was bleeding or thrombotic events. Bleeding events included a blood product transfusion >80 ml/kg on any day, pulmonary hemorrhage, or intracranial bleeding, Thrombotic events included pulmonary emboli, intracranial clot, limb ischemia, cardiac clot, and arterial cannula or entire circuit change. Bleeding occurred in 42% of patients. Five percent of subjects thrombosed, of which 89% also bled. Daily bleeding odds were independently associated with day prior activated clotting time (ACT) (OR 1.03, 95% CI= 1.00, 1.05, p=0.047) and fibrinogen levels (OR 0.90, 95% CI 0.84, 0.96, p <0.001). Thrombosis odds decreased with increased day prior heparin dose (OR 0.88, 95% CI 0.81, 0.97, p=0.006). Lower ACT values and increased fibrinogen levels may be considered to decrease the odds of bleeding. Use of this single measure, however, may not be sufficient alone to guide optimal anticoagulation practice during ECMO.
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Affiliation(s)
- David K Bailly
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, 14434University of Utah, Salt Lake, UT, USA
| | - Jennifer A Muszynski
- Division of Critical Care, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Department of Pediatrics, 2650Nationwide Children's Hospital, Columbus, OH, USA.,Center for Clinical and Translational Research, 2650The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA
| | - Kathleen L Meert
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Ashish A Ankola
- Department of Anesthesiology, Critical Care, and Pain Medicine, 1862Boston Children's Hospital, Boston, MA, USA.,Department of Cardiology, 1862Boston Children's Hospital, Boston, MA, USA
| | - Peta Ma Alexander
- Department of Pediatrics, 14434Harvard Medical School, Boston, MA, USA
| | - Murray M Pollack
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Frank W Moler
- Department of Pediatrics and Communicable Diseases, 1259University of Michigan, Ann Arbor, MI, USA
| | - Robert A Berg
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Critical Care Medicine, 6619Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine, 5150Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John Berger
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Michael J Bell
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - J M Dean
- Department of Pediatrics, Division of Pediatric Critical Care, 14434University of Utah, Salt Lake, UT, USA
| | - Carol Nicholson
- Trauma and Critical Illness Branch, 35040National Institute of Child Health and Human Development (NICHD), Bethesda, MD, USA.,35040National Institutes of Health, Bethesda, MD, USA
| | - Pamela Garcia-Filion
- Department of Biomedical Informatics, 14524Phoenix Children's Hospital, Phoenix, AZ, USA
| | - David Wessel
- Department of Pediatrics, 8404Children's National Hospital, Washington, DC, USA
| | - Sabrina Heidemann
- Department of Pediatrics, 2969Children's Hospital of Michigan, Detroit, MI, USA.,2969Central Michigan University, Mt. Pleasant, MI, USA
| | - Allan Doctor
- Department of Pediatrics and Center for Blood Oxygen Transport and Hemostasis, 12264University of Maryland, School of Medicine, Baltimore, MD, USA
| | - Rick Harrison
- Department of Pediatrics, 21785Mattel Children's Hospital UCLA, Los Angeles, CA, USA
| | - Heidi Dalton
- Department of Pediatrics and Heart and Vascular Institute, 3313Inova Fairfax Hospital, Fall Church, VA, USA
| | - Athena F Zuppa
- Department of Anesthesia and Critical Care, 6567Children's Hospital of Philadelphia, Philadelphia, PA, USA
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18
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Boutzoukas AE, Olson R, Sellers MA, Fischer G, Hornik CD, Alibrahim O, Iheagwara K, Abulebda K, Bass AL, Irby K, Subbaswamy A, Zivick EE, Sweney J, Stormorken AG, Barker EE, Lutfi R, McCrory MC, Costello JM, Ackerman KG, Munoz Pareja JC, Dean JM, Abdelsamad N, Hanley DF, Mould WA, Lane K, Stroud M, Feger BJ, Greenberg RG, Smith PB, Benjamin DK, Hornik CP, Zimmerman KO, Becker ML. Mechanisms to expedite pediatric clinical trial site activation: The DOSE trial experience. Contemp Clin Trials 2023; 125:107067. [PMID: 36577492 PMCID: PMC9918704 DOI: 10.1016/j.cct.2022.107067] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/17/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
BACKGROUND Timely trial start-up is a key determinant of trial success; however, delays during start-up are common and costly. Moreover, data on start-up metrics in pediatric clinical trials are sparse. To expedite trial start-up, the Trial Innovation Network piloted three novel mechanisms in the trial titled Dexmedetomidine Opioid Sparing Effect in Mechanically Ventilated Children (DOSE), a multi-site, randomized, double-blind, placebo-controlled trial in the pediatric intensive care setting. METHODS The three novel start-up mechanisms included: 1) competitive activation; 2) use of trial start-up experts, called site navigators; and 3) supplemental funds earned for achieving pre-determined milestones. After sites were activated, they received a web-based survey to report perceptions of the DOSE start-up process. In addition to perceptions, metrics analyzed included milestones met, time to start-up, and subsequent enrollment of subjects. RESULTS Twenty sites were selected for participation, with 19 sites being fully activated. Across activated sites, the median (quartile 1, quartile 3) time from receipt of regulatory documents to site activation was 82 days (68, 113). Sites reported that of the three novel mechanisms, the most motivating factor for expeditious activation was additional funding available for achieving start-up milestones, followed by site navigator assistance and then competitive site activation. CONCLUSION Study start-up is a critical time for the success of clinical trials, and innovative methods to minimize delays during start-up are needed. Milestone-based funds and site navigators were preferred mechanisms by sites participating in the DOSE study and may have contributed to the expeditious start-up timeline achieved. CLINICALTRIALS gov #: NCT03938857.
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Affiliation(s)
- Angelique E Boutzoukas
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Rachel Olson
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Gwenyth Fischer
- University of Minnesota Masonic Children's Hospital, Minneapolis, MN, USA
| | - Chi D Hornik
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kamal Abulebda
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Andora L Bass
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | | | | | | | - Jill Sweney
- Primary Children's Medical Center, University of Utah, Salt Lake City, UT, USA
| | | | | | - Riad Lutfi
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | | | | | | | | | | | | | - Daniel F Hanley
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - W Andrew Mould
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Karen Lane
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mary Stroud
- Vanderbilt Institute for Clinical and Translational Research, Nashville, TN, USA
| | | | - Rachel G Greenberg
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - P Brian Smith
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Daniel K Benjamin
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Christoph P Hornik
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Kanecia O Zimmerman
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA
| | - Mara L Becker
- Duke Clinical Research Institute, Durham, NC, USA; Duke University School of Medicine, Durham, NC, USA.
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19
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Zantek ND, Steiner ME, VanBuren JM, Lewis RJ, Berry NS, Viele K, Krachey E, Dean JM, Nelson S, Spinella PC. Design and logistical considerations for the randomized adaptive non-inferiority storage-duration-ranging CHIlled Platelet Study. Clin Trials 2023; 20:36-46. [PMID: 36541257 DOI: 10.1177/17407745221126423] [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] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Platelet transfusion is a potentially life-saving therapy for actively bleeding patients, ranging from those undergoing planned surgical procedures to those suffering unexpected traumatic injuries. Platelets are currently stored at room temperature (20°C-24°C) with a maximum storage duration of 7 days after donation. The CHIlled Platelet Study trial will compare the efficacy and safety of standard room temperature-stored platelets with platelets that are cold-stored (1°C-6°C), that is, chilled, with a maximum of storage up to 21 days in adult and pediatric patients undergoing complex cardiac surgical procedures. METHODS/RESULTS CHIlled Platelet Study will use a Bayesian adaptive design to identify the range of cold storage durations for platelets that are non-inferior to standard room temperature-stored platelets. If cold-stored platelets are non-inferior at durations greater than 7 days, a gated superiority analysis will identify durations for which cold-stored platelets may be superior to standard platelets. We present example simulations of the CHIlled Platelet Study design and discuss unique challenges in trial implementation. The CHIlled Platelet Study trial has been funded and will be implemented in approximately 20 clinical centers. Early randomization to enable procurement of cold-stored platelets with different storage durations will be required, as well as a platelet tracking system to eliminate platelet wastage and maximize trial efficiency and economy. DISCUSSION The CHIlled Platelet Study trial will determine whether cold-stored platelets are non-inferior to platelets stored at room temperature, and if so, will determine the maximum duration (up to 21 days) of storage that maintains non-inferiority. TRIAL REGISTRATION ClinicalTrials.gov, NCT04834414.
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Affiliation(s)
- Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Roger J Lewis
- Harbor-UCLA Medical Center, Torrance, CA, USA.,David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Berry Consultants, Austin, TX, USA
| | | | | | | | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Philip C Spinella
- Department of Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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20
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Berg RA, Morgan RW, Reeder RW, Ahmed T, Bell MJ, Bishop R, Bochkoris M, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fernandez R, Fink EL, Franzon D, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Meert KL, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Sapru A, Schneiter C, Sharron MP, Srivastava N, Tabbutt S, Tilford B, Viteri S, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM. Diastolic Blood Pressure Threshold During Pediatric Cardiopulmonary Resuscitation and Survival Outcomes: A Multicenter Validation Study. Crit Care Med 2023; 51:91-102. [PMID: 36519983 PMCID: PMC9970166 DOI: 10.1097/ccm.0000000000005715] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Arterial diastolic blood pressure (DBP) greater than 25 mm Hg in infants and greater than 30 mm Hg in children greater than 1 year old during cardiopulmonary resuscitation (CPR) was associated with survival to hospital discharge in one prospective study. We sought to validate these potential hemodynamic targets in a larger multicenter cohort. DESIGN Prospective observational study. SETTING Eighteen PICUs in the ICU-RESUScitation prospective trial from October 2016 to March 2020. PATIENTS Children less than or equal to 18 years old with CPR greater than 30 seconds and invasive blood pressure (BP) monitoring during CPR. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Invasive BP waveform data and Utstein-style CPR data were collected, including prearrest patient characteristics, intra-arrest interventions, and outcomes. Primary outcome was survival to hospital discharge, and secondary outcomes were return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Multivariable Poisson regression models with robust error estimates evaluated the association of DBP greater than 25 mm Hg in infants and greater than 30 mm Hg in older children with these outcomes. Among 1,129 children with inhospital cardiac arrests, 413 had evaluable DBP data. Overall, 85.5% of the patients attained thresholds of mean DBP greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in older children. Initial return of circulation occurred in 91.5% and 25% by placement on extracorporeal membrane oxygenator. Survival to hospital discharge occurred in 58.6%, and survival with favorable neurologic outcome in 55.4% (i.e. 94.6% of survivors had favorable neurologic outcomes). Mean DBP greater than 25 mm Hg for infants and greater than 30 mm Hg for older children was significantly associated with survival to discharge (adjusted relative risk [aRR], 1.32; 1.01-1.74; p = 0.03) and ROSC (aRR, 1.49; 1.12-1.97; p = 0.002) but did not reach significance for survival to hospital discharge with favorable neurologic outcome (aRR, 1.30; 0.98-1.72; p = 0.051). CONCLUSIONS These validation data demonstrate that achieving mean DBP during CPR greater than 25 mm Hg for infants and greater than 30 mm Hg for older children is associated with higher rates of survival to hospital discharge, providing potential targets for DBP during CPR.
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Affiliation(s)
- Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Aisha H Frazier
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
- Department of Pediatrics, University of Arkansas for Medical Sciences, and Arkansas Children's Research Institute, Little Rock, AR
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Shirley Viteri
- Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
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Abstract
The Collaborative Pediatric Critical Care Research Network (CPCCRN) was established by the Eunice Kennedy Shriver National Institute of Child Health and Human Development in May 2005 to develop an infrastructure for collaborative clinical trials and meaningful descriptive studies in pediatric critical care. This article describes the history of CPCCRN, discusses its financial and organizational structure, illustrates how funds were efficiently used to carry out studies, and describes CPCCRN public use datasets and future directions, concluding with the development of the PeRsonalizEd Immunomodulation in PediatriC SepsIS-InducEd MODS study.
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Affiliation(s)
- J Michael Dean
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
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22
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Horvat CM, Fabio A, Nagin DS, Banks RK, Qin Y, Park HJ, Kernan KF, Canna SW, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Reeder RW, Sward K, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Mortality Risk in Pediatric Sepsis Based on C-reactive Protein and Ferritin Levels. Pediatr Crit Care Med 2022; 23:968-979. [PMID: 36178701 PMCID: PMC9722561 DOI: 10.1097/pcc.0000000000003074] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Interest in using bedside C-reactive protein (CRP) and ferritin levels to identify patients with hyperinflammatory sepsis who might benefit from anti-inflammatory therapies has piqued with the COVID-19 pandemic experience. Our first objective was to identify patterns in CRP and ferritin trajectory among critically ill pediatric sepsis patients. We then examined the association between these different groups of patients in their inflammatory cytokine responses, systemic inflammation, and mortality risks. DATA SOURCES A prospective, observational cohort study. STUDY SELECTION Children with sepsis and organ failure in nine pediatric intensive care units in the United States. DATA EXTRACTION Two hundred and fifty-five children were enrolled. Five distinct clinical multi-trajectory groups were identified. Plasma CRP (mg/dL), ferritin (ng/mL), and 31 cytokine levels were measured at two timepoints during sepsis (median Day 2 and Day 5). Group-based multi-trajectory models (GBMTM) identified groups of children with distinct patterns of CRP and ferritin. DATA SYNTHESIS Group 1 had normal CRP and ferritin levels ( n = 8; 0% mortality); Group 2 had high CRP levels that became normal, with normal ferritin levels throughout ( n = 80; 5% mortality); Group 3 had high ferritin levels alone ( n = 16; 6% mortality); Group 4 had very high CRP levels, and high ferritin levels ( n = 121; 11% mortality); and Group 5 had very high CRP and very high ferritin levels ( n = 30; 40% mortality). Cytokine responses differed across the five groups, with ferritin levels correlated with macrophage inflammatory protein 1α levels and CRP levels reflective of many cytokines. CONCLUSIONS Bedside CRP and ferritin levels can be used together to distinguish groups of children with sepsis who have different systemic inflammation cytokine responses and mortality risks. These data suggest future potential value in personalized clinical trials with specific targets for anti-inflammatory therapies.
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Affiliation(s)
- Christopher M. Horvat
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Anthony Fabio
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | - Daniel S. Nagin
- Department of Statistics, Carnegie Mellon University, Pittsburgh, PA
| | | | - Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Kate F. Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Scott W. Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Robert A. Berg
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Murray M. Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children’s National Hospital, Washington, DC
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit, MI., Central Michigan University, Mt Pleasant MI
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital Immune Surveillance Laboratory, and Nationwide Children’s Hospital, Columbus, OH
| | - Christopher Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children’s Hospital Los Angeles, Los Angeles, CA
| | - John C. Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children’s Hospital, St. Louis, MO
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children’s Hospital, Ann Arbor, MI
| | - Rick E. Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children’s Hospital at University of California Los Angeles, Los Angeles, CA
| | - Athena F. Zuppa
- Department of Anesthesiology, Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | | | | | | | | | - Joseph A. Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
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23
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Burr JS, Johnson A, Risenmay A, Bisping S, Serdoz ES, Coleman W, Sward KA, Rothwell E, Dean JM. Demonstration Project: Transitioning a Research Network to New Single IRB Platforms. Ethics Hum Res 2022; 44:32-38. [PMID: 36316971 PMCID: PMC10328109 DOI: 10.1002/eahr.500149] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Since the 2016 National Institutes of Health (NIH) mandate to use a single IRB (sIRB) in multicenter research, institutions have struggled to operationalize the process. In this demonstration project, the University of Utah Trial Innovation Center assisted the Collaborative Pediatric Critical Care Research Network to transition from using individually negotiated reliance agreements and paper-based documentation to a new sIRB master agreement and an informatics platform to capture reliance documentation. Lessons learned that can guide other academic institutions and IRBs as they operationalize sIRBs included the need for sites to understand what type of engagement or reliance is required and their need to understand the difference between reliance and activation. Requirements around local review remain poorly understood. Further research is needed to determine approaches that can achieve the NIH vision of reviews becoming more efficient and improving study start-up times, relieving administrative burden while advancing human research protections.
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Affiliation(s)
- Jeri S Burr
- Executive director of the Trial Innovation Center at the University of Utah
| | - Ann Johnson
- Director of the Institutional Review Board and Human Research Protection Program at the University of Utah
| | | | | | - Emily S Serdoz
- Manager of translational research at the Vanderbilt University Medical Center
| | - Whit Coleman
- Education support manager at Ashfield Healthcare
| | - Katherine A Sward
- Professor at the College of Nursing in the Department of Biomedical Informatics
| | - Erin Rothwell
- Associate vice president for research and a professor in the Department of Obstetrics and Gynecology at the University of Utah
| | - J Michael Dean
- Associate dean for clinical research and a director and principal investigator at Trial Innovation Center and the Collaborative Pediatric Critical Care Research Network, and a professor in the Department of Pediatrics at the University of Utah School of Medicine
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24
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Johnson AR, Pautler M, Burr JS, Abdelsamad N, VanBuren JM, Rigtrup LM, Dean JM, Rothwell E. Using single IRB consultations to meet the educational needs of investigative teams. Contemp Clin Trials Commun 2022; 29:100971. [PMID: 36033361 PMCID: PMC9403494 DOI: 10.1016/j.conctc.2022.100971] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/08/2022] [Accepted: 08/07/2022] [Indexed: 11/17/2022] Open
Abstract
Single IRB (SIRB) consultation resources were established by the Utah Trial Innovation Center to assist and educate investigative teams prior to the submission of funding applications for multisite, cooperative research. Qualitative analysis of the written consultation materials and meeting minutes revealed the most common areas of education needed by investigative teams, including (a) the differences and relationships between the IRB and a Human Research Protection Program (HRPP); (b) the main phases of the SIRB process; and (c) the use of technology platforms for documentation of SIRB review processes. For investigative teams who are inexperienced with using a SIRB, such consultation in the pre-award period is likely to fill in knowledge gaps and improve the study start-up process.
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Affiliation(s)
- Ann R. Johnson
- University of Utah, Institutional Review Board, 75 S 2000 E, Salt Lake City, UT, 84112, USA
- Corresponding author.
| | - Mary Pautler
- University of Utah School of Medicine, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Jeri S. Burr
- University of Utah School of Medicine, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Nael Abdelsamad
- University of Utah School of Medicine, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - John M. VanBuren
- University of Utah School of Medicine, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Lisa M. Rigtrup
- University of Utah, Institutional Review Board, 75 S 2000 E, Salt Lake City, UT, 84112, USA
| | - J. Michael Dean
- University of Utah School of Medicine, Department of Pediatrics, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Erin Rothwell
- University of Utah School of Medicine, Department of Obstetrics and Gynecology, 50 North Medical Drive, Salt Lake City, UT, 84132, USA
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25
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Cashen K, Reeder RW, Ahmed T, Bell MJ, Berg RA, Burns C, Carcillo JA, Carpenter TC, Dean JM, Diddle JW, Federman M, Fink EL, Frazier AH, Friess SH, Graham K, Hall M, Hehir DA, Horvat CM, Huard LL, Maa T, Manga A, McQuillen PS, Morgan RW, Mourani PM, Nadkarni VM, Naim MY, Notterman D, Palmer CA, Pollack MM, Schneiter C, Sharron MP, Srivastava N, Wessel D, Wolfe HA, Yates AR, Zuppa AF, Sutton RM, Meert KL. Sodium Bicarbonate Use During Pediatric Cardiopulmonary Resuscitation: A Secondary Analysis of the ICU-RESUScitation Project Trial. Pediatr Crit Care Med 2022; 23:784-792. [PMID: 35880872 PMCID: PMC9529841 DOI: 10.1097/pcc.0000000000003045] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To evaluate associations between sodium bicarbonate use and outcomes during pediatric in-hospital cardiac arrest (p-IHCA). DESIGN Prespecified secondary analysis of a prospective, multicenter cluster randomized interventional trial. SETTING Eighteen participating ICUs of the ICU-RESUScitation Project (NCT02837497). PATIENTS Children less than or equal to 18 years old and greater than or equal to 37 weeks post conceptual age who received chest compressions of any duration from October 2016 to March 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Child and event characteristics, prearrest laboratory values (2-6 hr prior to p-IHCA), pre- and intraarrest hemodynamics, and outcomes were collected. In a propensity score weighted cohort, the relationships between sodium bicarbonate use and outcomes were assessed. The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and survival to hospital discharge with favorable neurologic outcome. Of 1,100 index cardiopulmonary resuscitation events, median age was 0.63 years (interquartile range, 0.19-3.81 yr); 528 (48.0%) received sodium bicarbonate; 773 (70.3%) achieved ROSC; 642 (58.4%) survived to hospital discharge; and 596 (54.2%) survived to hospital discharge with favorable neurologic outcome. Among the weighted cohort, sodium bicarbonate use was associated with lower survival to hospital discharge rate (adjusted odds ratio [aOR], 0.7; 95% CI, 0.54-0.92; p = 0.01) and lower survival to hospital discharge with favorable neurologic outcome rate (aOR, 0.69; 95% CI, 0.53-0.91; p = 0.007). Sodium bicarbonate use was not associated with ROSC (aOR, 0.91; 95% CI, 0.62-1.34; p = 0.621). CONCLUSIONS In this propensity weighted multicenter cohort study of p-IHCA, sodium bicarbonate use was common and associated with lower rates of survival to hospital discharge.
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Affiliation(s)
- Katherine Cashen
- Department of Pediatrics, Duke Children's Hospital, Duke University, Durham, NC
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Michael J Bell
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Candice Burns
- Department of Pediatrics and Human Development, Michigan State University, Grand Rapids, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Aisha H Frazier
- Department of Pediatrics, Nemours Cardiac Center, Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE
- Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - David A Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
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26
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Sward KA, Enriquez R, Burr J, Ozier J, Roebuck M, Elliott C, Dean JM. Consent Builder: an innovative tool for creating research informed consent documents. JAMIA Open 2022; 5:ooac069. [PMID: 35911667 PMCID: PMC9329658 DOI: 10.1093/jamiaopen/ooac069] [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: 11/29/2021] [Revised: 05/30/2022] [Accepted: 07/20/2022] [Indexed: 11/12/2022] Open
Abstract
Objective To describe process innovations related to research informed consent documents, and development and formative evaluation of Consent Builder, a platform for generating consent documents for multicenter studies. Materials and Methods Analysis of Institutional Review Board workflows and documents, followed by process redesign, document redesign, and software development. Locally developed software leverages REDCap and LaTeX. A small-scale usability study was conducted. Results Process innovations were combining document types, and conceptualizing 2-part informed consent documents: part 1 standardizing the study description and part 2 with local site verbiage. Consent Builder was implemented in the Trial Innovation Network. User survey scores were acceptable; but areas for improvement were noted. LaTeX coding was the biggest challenge for users. Discussion The process changes were generally well accepted. The software implementation uncovered un-accounted for assumptions, and variability in IRB review workflow across centers. Technical modifications may be needed before widespread implementation. Conclusion We demonstrated proof-of-concept of an approach to generate research consent documents that are consistent across sites in study description, but which allow for customization of local site verbiage. The Consent Builder tool is an example of an operational innovation, helping meet a need that arose in part due to regulations around use of Single IRB for multicenter trials.
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Affiliation(s)
- Katherine A Sward
- Department of Nursing, University of Utah, Salt Lake City, Utah, USA
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Rene Enriquez
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Jeri Burr
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Julie Ozier
- Human Research Protection Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Megan Roebuck
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - Carrie Elliott
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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Ames SG, Banks RK, Zinter MS, Fink EL, McQuillen PS, Hall MW, Zuppa A, Meert KL, Mourani PM, Carcillo JA, Carpenter T, Pollack MM, Berg RA, Mareboina M, Holubkov R, Dean JM, Notterman DA, Sapru A. Assessment of Patient Health-Related Quality of Life and Functional Outcomes in Pediatric Acute Respiratory Distress Syndrome. Pediatr Crit Care Med 2022; 23:e319-e328. [PMID: 35452018 DOI: 10.1097/pcc.0000000000002959] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe health-related quality of life (HRQL) and functional outcomes in pediatric acute respiratory distress syndrome (ARDS) and to determine risk factors associated with poor outcome defined as death or severe reduction in HRQL at 28 days or ICU discharge. DESIGN Prospective multisite cohort-outcome study conducted between 2019 and 2020. SETTING Eight academic PICUs in the United States. PATIENTS Children with ARDS based on standard criteria. INTERVENTIONS Patient characteristics and illness severity were collected during PICU admission. Parent proxy-report measurements were obtained at baseline, day 28/ICU discharge, month 3, and month 9, utilizing Pediatric Quality of Life Inventory and Functional Status Scale (FSS). A composite outcome evaluated using univariate and multivariate analysis was death or severe reduction in HRQL (>25% reduction in the Pediatric Quality of Life Inventory at day 28/ICU discharge. MEASUREMENTS AND MAIN RESULTS This study enrolled 122 patients with a median age of 3 years (interquartile range, 1-12 yr). Common etiologies of ARDS included pneumonia ( n = 63; 52%) and sepsis ( n = 27; 22%). At day 28/ICU discharge, half (50/95; 53%) of surviving patients with follow-up data reported a greater than 10% decrease in HRQL from baseline, and approximately one-third of participants ( n = 19/61; 31%) reported a greater than 10% decrease in HRQL at 9 months. Trends in FSS were similar. Of 104 patients with data, 47 patients (45%) died or reported a severe decrease of greater than 25% in HRQL at day 28/ICU discharge. Older age was associated with an increased risk of death or severe reduction in HRQL (odds ratio, 1.08; CI, 1.01-1.16). CONCLUSIONS Children with ARDS are at risk for deterioration in HRQL and FSS that persists up to 9 months after ARDS. Almost half of children with ARDS experience a poor outcome including death or severe reduction in HRQL at day 28/ICU discharge.
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Affiliation(s)
| | | | - Matt S Zinter
- Benioff Children's Hospital, University of California-San Francisco, San Francisco, CA
| | - Ericka L Fink
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S McQuillen
- Benioff Children's Hospital, University of California-San Francisco, San Francisco, CA
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | - Athena Zuppa
- Children's Hospital of Philadelphia, Philadelphia, PA
| | | | | | - Joseph A Carcillo
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, PA
| | - Manvita Mareboina
- Mattel Children's Hospital, University of California-Los Angeles, Los Angeles, CA
| | | | | | | | - Anil Sapru
- Mattel Children's Hospital, University of California-Los Angeles, Los Angeles, CA
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Marrouche NF, Wazni O, McGann C, Greene T, Dean JM, Dagher L, Kholmovski E, Mansour M, Marchlinski F, Wilber D, Hindricks G, Mahnkopf C, Wells D, Jais P, Sanders P, Brachmann J, Bax JJ, Morrison-de Boer L, Deneke T, Calkins H, Sohns C, Akoum N. Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The DECAAF II Randomized Clinical Trial. JAMA 2022; 327:2296-2305. [PMID: 35727277 PMCID: PMC9214588 DOI: 10.1001/jama.2022.8831] [Citation(s) in RCA: 109] [Impact Index Per Article: 54.5] [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] [Received: 11/24/2021] [Accepted: 05/11/2022] [Indexed: 11/14/2022]
Abstract
Importance Ablation of persistent atrial fibrillation (AF) remains a challenge. Left atrial fibrosis plays an important role in the pathophysiology of AF and has been associated with poor procedural outcomes. Objective To investigate the efficacy and adverse events of targeting atrial fibrosis detected on magnetic resonance imaging (MRI) in reducing atrial arrhythmia recurrence in persistent AF. Design, Setting, and Participants The Efficacy of Delayed Enhancement-MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation of Atrial Fibrillation trial was an investigator-initiated, multicenter, randomized clinical trial involving 44 academic and nonacademic centers in 10 countries. A total of 843 patients with symptomatic or asymptomatic persistent AF and undergoing AF ablation were enrolled from July 2016 to January 2020, with follow-up through February 19, 2021. Interventions Patients with persistent AF were randomly assigned to pulmonary vein isolation (PVI) plus MRI-guided atrial fibrosis ablation (421 patients) or PVI alone (422 patients). Delayed-enhancement MRI was performed in both groups before the ablation procedure to assess baseline atrial fibrosis and at 3 months postablation to assess for ablation scar. Main Outcomes and Measures The primary end point was time to first atrial arrhythmia recurrence after a 90-day blanking period postablation. The primary safety composite outcome was defined by the occurrence of 1 or more of the following events within 30 days postablation: stroke, PV stenosis, bleeding, heart failure, or death. Results Among 843 patients who were randomized (mean age 62.7 years; 178 [21.1%] women), 815 (96.9%) completed the 90-day blanking period and contributed to the efficacy analyses. There was no significant difference in atrial arrhythmia recurrence between groups (fibrosis-guided ablation plus PVI patients, 175 [43.0%] vs PVI-only patients, 188 [46.1%]; hazard ratio [HR], 0.95 [95% CI, 0.77-1.17]; P = .63). Patients in the fibrosis-guided ablation plus PVI group experienced a higher rate of safety outcomes (9 [2.2%] vs 0 in PVI group; P = .001). Six patients (1.5%) in the fibrosis-guided ablation plus PVI group had an ischemic stroke compared with none in PVI-only group. Two deaths occurred in the fibrosis-guided ablation plus PVI group, and the first one was possibly related to the procedure. Conclusions and Relevance Among patients with persistent AF, MRI-guided fibrosis ablation plus PVI, compared with PVI catheter ablation only, resulted in no significant difference in atrial arrhythmia recurrence. Findings do not support the use of MRI-guided fibrosis ablation for the treatment of persistent AF. Trial Registration ClinicalTrials.gov Identifier: NCT02529319.
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Affiliation(s)
- Nassir F. Marrouche
- Cardiology Department, Tulane University School of Medicine, New Orleans, Louisiana
| | | | | | | | | | - Lilas Dagher
- Cardiology Department, Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Moussa Mansour
- Cardiology Department, Massachusetts General Hospital, Boston
| | | | - David Wilber
- Cardiology Department, Loyola University Chicago, Chicago, Illinois
| | | | | | | | - Pierre Jais
- Cardiology Department, Segalen University, Bordeaux, France
| | | | | | - Jeroen J. Bax
- Cardiology Department, Leiden University Medical Center, Leiden, the Netherlands
- Cardiology Department, Turku Heart Center, Turku, Finland
| | | | | | - Hugh Calkins
- Cardiology Department, Johns Hopkins University, Baltimore, Maryland
| | | | - Nazem Akoum
- Cardiology Department, University of Washington Medical Center, Seattle
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29
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Qin Y, Kernan KF, Fan Z, Park HJ, Kim S, Canna SW, Kellum JA, Berg RA, Wessel D, Pollack MM, Meert K, Hall M, Newth C, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Michael Dean J, Carcillo JA. Machine learning derivation of four computable 24-h pediatric sepsis phenotypes to facilitate enrollment in early personalized anti-inflammatory clinical trials. Crit Care 2022; 26:128. [PMID: 35526000 PMCID: PMC9077858 DOI: 10.1186/s13054-022-03977-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 04/03/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thrombotic microangiopathy-induced thrombocytopenia-associated multiple organ failure and hyperinflammatory macrophage activation syndrome are important causes of late pediatric sepsis mortality that are often missed or have delayed diagnosis. The National Institutes of General Medical Science sepsis research working group recommendations call for application of new research approaches in extant clinical data sets to improve efficiency of early trials of new sepsis therapies. Our objective is to apply machine learning approaches to derive computable 24-h sepsis phenotypes to facilitate personalized enrollment in early anti-inflammatory trials targeting these conditions. METHODS We applied consensus, k-means clustering analysis to our extant PHENOtyping sepsis-induced Multiple organ failure Study (PHENOMS) dataset of 404 children. 24-hour computable phenotypes are derived using 25 available bedside variables including C-reactive protein and ferritin. RESULTS Four computable phenotypes (PedSep-A, B, C, and D) are derived. Compared to all other phenotypes, PedSep-A patients (n = 135; 2% mortality) were younger and previously healthy, with the lowest C-reactive protein and ferritin levels, the highest lymphocyte and platelet counts, highest heart rate, and lowest creatinine (p < 0.05); PedSep-B patients (n = 102; 12% mortality) were most likely to be intubated and had the lowest Glasgow Coma Scale Score (p < 0.05); PedSep-C patients (n = 110; mortality 10%) had the highest temperature and Glasgow Coma Scale Score, least pulmonary failure, and lowest lymphocyte counts (p < 0.05); and PedSep-D patients (n = 56, 34% mortality) had the highest creatinine and number of organ failures, including renal, hepatic, and hematologic organ failure, with the lowest platelet counts (p < 0.05). PedSep-D had the highest likelihood of developing thrombocytopenia-associated multiple organ failure (Adj OR 47.51 95% CI [18.83-136.83], p < 0.0001) and macrophage activation syndrome (Adj OR 38.63 95% CI [13.26-137.75], p < 0.0001). CONCLUSIONS Four computable phenotypes are derived, with PedSep-D being optimal for enrollment in early personalized anti-inflammatory trials targeting thrombocytopenia-associated multiple organ failure and macrophage activation syndrome in pediatric sepsis. A computer tool for identification of individual patient membership ( www.pedsepsis.pitt.edu ) is provided. Reproducibility will be assessed at completion of two ongoing pediatric sepsis studies.
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Affiliation(s)
- Yidi Qin
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Zhenjiang Fan
- Department of Computer Sciences, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Soyeon Kim
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Scott W Canna
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - John A Kellum
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA
| | - Robert A Berg
- Department of Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher Newth
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | | | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Athena F Zuppa
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Russell Banks
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Ron W Reeder
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Richard Holubkov
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Daniel A Notterman
- University of Utah, Salt Lake City, UT, USA
- Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Faculty Pavilion, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Suite 2000, 4400 Penn Avenue, Pittsburgh, PA, 15421, USA.
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30
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Johnson AR, Kasimatis Singleton M, Ozier J, Serdoz E, Beadles JG, Maddox-Regis J, Mumford S, Burr J, Dean JM, Ford DE, Bernard GR. Key lessons and strategies for implementing single IRB review in the Trial Innovation Network. J Clin Transl Sci 2022; 6:e53. [PMID: 35656335 PMCID: PMC9120617 DOI: 10.1017/cts.2022.391] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 12/03/2021] [Revised: 03/22/2022] [Accepted: 04/12/2022] [Indexed: 11/05/2022] Open
Abstract
The Trial Innovation Network has established an infrastructure for single IRB review in response to federal policies. The Network's single IRB (sIRBs) have successfully supported over 70 multisite studies via more than 800 reliance arrangements. This has generated several lessons learned that can benefit the national clinical research enterprise, as we work to improve the conduct of clinical trials. These lessons include distinguishing the roles of the single IRB from institutional Human Research Protections programs, establishing a consistent sIRB review model, standardizing collection of local context and supplemental, study-specific information, and educating and empowering lead study teams to support their sites.
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Affiliation(s)
- Ann R. Johnson
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | | | - Julie Ozier
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Emily Serdoz
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Sarah Mumford
- University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Jeri Burr
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - J. Michael Dean
- University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Daniel E. Ford
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
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31
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Yates AR, Berger JT, Reeder RW, Banks R, Mourani PM, Berg RA, Carcillo JA, Carpenter T, Hall MW, Meert KL, McQuillen PS, Pollack MM, Sapru A, Notterman DA, Holubkov R, Dean JM, Wessel DL. Characterization of Inhaled Nitric Oxide Use for Cardiac Indications in Pediatric Patients. Pediatr Crit Care Med 2022; 23:245-254. [PMID: 35200229 PMCID: PMC9058189 DOI: 10.1097/pcc.0000000000002917] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Characterize the use of inhaled nitric oxide (iNO) for pediatric cardiac patients and assess the relationship between patient characteristics before iNO initiation and outcomes following cardiac surgery. DESIGN Observational cohort study. SETTING PICU and cardiac ICUs in seven Collaborative Pediatric Critical Care Research Network hospitals. PATIENTS Consecutive patients, less than 18 years old, mechanically ventilated before or within 24 hours of iNO initiation. iNO was started for a cardiac indication and excluded newborns with congenital diaphragmatic hernia, meconium aspiration syndrome, and persistent pulmonary hypertension, or when iNO started at an outside institution. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Four-hundred seven patients with iNO initiation based on cardiac dysfunction. Cardiac dysfunction patients were administered iNO for a median of 4 days (2-7 d). There was significant morbidity with 51 of 407 (13%) requiring extracorporeal membrane oxygenation and 27 of 407 (7%) requiring renal replacement therapy after iNO initiation, and a 28-day mortality of 46 of 407 (11%). Of the 366 (90%) survivors, 64 of 366 patients (17%) had new morbidity as assessed by Functional Status Scale. Among the postoperative cardiac surgical group (n = 301), 37 of 301 (12%) had a superior cavopulmonary connection and nine of 301 (3%) had a Fontan procedure. Based on echocardiographic variables prior to iNO (n = 160) in the postoperative surgical group, right ventricle dysfunction was associated with 28-day and hospital mortalities (both, p < 0.001) and ventilator-free days (p = 0.003); tricuspid valve regurgitation was only associated with ventilator-free days (p < 0.001), whereas pulmonary hypertension was not associated with mortality or ventilator-free days. CONCLUSIONS Pediatric patients in whom iNO was initiated for a cardiac indication had a high mortality rate and significant morbidity. Right ventricular dysfunction, but not the presence of pulmonary hypertension on echocardiogram, was associated with ventilator-free days and mortality.
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Affiliation(s)
- Andrew R. Yates
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | | | | | | | - Peter M. Mourani
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Robert A. Berg
- The Children’s Hospital of Philadelphia, Philadelphia, PA
| | | | - Todd Carpenter
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Mark W. Hall
- Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Kathleen L. Meert
- Children’s Hospital of Michigan, Detroit, Michigan; Central Michigan University, Mt. Pleasant, MI
| | | | | | - Anil Sapru
- Mattel Children’s Hospital, Los Angeles, CA
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32
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Nishijima DK, VanBuren JM, Linakis SW, Hewes HA, Myers SR, Bobinski M, Tran NK, Ghetti S, Adelson PD, Roberts I, Holmes JF, Schalick WO, Dean JM, Casper TC, Kuppermann N. Traumatic injury clinical trial evaluating tranexamic acid in children (TIC-TOC): a pilot randomized trial. Acad Emerg Med 2022; 29:10.1111/acem.14481. [PMID: 35266589 PMCID: PMC9463410 DOI: 10.1111/acem.14481] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The antifibrinolytic drug tranexamic acid (TXA) improves survival in adults with traumatic hemorrhage; however, the drug has not been evaluated in a trial in injured children. We evaluated the feasibility of a large-scale trial evaluating the effects of TXA in children with severe hemorrhagic injuries. METHODS Severely injured children (0 up to 18th birthday) were randomized into a double-blind randomized trial of 1) TXA 15 mg/kg bolus dose, followed by 2 mg/kg/hr infusion over 8 hours, 2) TXA 30 mg/kg bolus dose, followed by 4 mg/kg/hr infusion over 8 hours, or 3) normal saline placebo bolus and infusion. The trial was conducted at 4 pediatric Level I trauma centers in the United States between June 2018 and March 2020. We enrolled patients under federal exception from informed consent (EFIC) procedures when parents were unable to provide informed consent. Feasibility outcomes included the rate of enrollment, adherence to intervention arms, and ability to measure the primary clinical outcome. Clinical outcomes included global functioning (primary), working memory, total amount of blood products transfused, intracranial hemorrhage progression, and adverse events. The target enrollment rate was at least 1.25 patients per site per month. RESULTS A total of 31 patients were randomized with a mean age of 10.7 years (standard deviation [SD] 5.0 years) and 22 (71%) patients were male. The mean time from injury to randomization was 2.4 hours (SD 0.6 hours). Sixteen (52%) patients had isolated brain injuries and 15 (48%) patients had isolated torso injuries. The enrollment rate using EFIC was 1.34 patients per site per month. All eligible enrolled patients received study intervention (9 patients TXA 15 mg/kg bolus dose, 10 patients TXA 30 mg/kg bolus dose, and 12 patients placebo) and had the primary outcome measured. No statistically significant differences in any of the clinical outcomes were identified. CONCLUSION Based on enrollment rate, protocol adherence, and measurement of the primary outcome in this pilot trial, we confirmed the feasibility of conducting a large-scale, randomized trial evaluating the efficacy of TXA in severely injured children with hemorrhagic brain and/or torso injuries using EFIC.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Seth W Linakis
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ohio State University School of Medicine, Nationwide Children's Hospital, 700 Children's Dr, Columbus, OH, 43205, USA
| | - Hilary A Hewes
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Utah School of Medicine, Primary Children's Hospital, 100 N. Mario Capecchi Dr, Salt Lake City, UT, 84113, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Philadelphia, 3401 Civic Center Blvd. Philadelphia, PA, USA, 19104
| | - Matthew Bobinski
- Department of Radiology, UC Davis School of Medicine, Stockton Blvd. Sacramento, CA, 95817, USA
| | - Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California, Davis, 4400 V. Street, CA, 95816, USA
| | - Simona Ghetti
- Department of Psychology, University of California, Davis, 102K Young Hall, 1 Shields Ave. Davis, CA, 95616, USA
| | - P David Adelson
- Department of Pediatric Neurosciences, Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Rd, Phoenix, AZ, 85016, USA
| | - Ian Roberts
- Clinical Trials Unit, School of Hygiene and Tropical Medicine, Keppel Street, WC1E 7HT, London, UK
| | - James F Holmes
- Department of Emergency Medicine, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
| | - Walton O Schalick
- Department of Orthopedics and Rehabilitation, University of Wisconsin, 317 Knutson Drive, Madison, WI, 53704, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT, 84108, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, UC Davis School of Medicine, 4150 V. Street, PSSB 2100, Sacramento, CA, 95817, USA
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33
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Sutton RM, Wolfe HA, Reeder RW, Ahmed T, Bishop R, Bochkoris M, Burns C, Diddle JW, Federman M, Fernandez R, Franzon D, Frazier AH, Friess SH, Graham K, Hehir D, Horvat CM, Huard LL, Landis WP, Maa T, Manga A, Morgan RW, Nadkarni VM, Naim MY, Palmer CA, Schneiter C, Sharron MP, Siems A, Srivastava N, Tabbutt S, Tilford B, Viteri S, Berg RA, Bell MJ, Carcillo JA, Carpenter TC, Dean JM, Fink EL, Hall M, McQuillen PS, Meert KL, Mourani PM, Notterman D, Pollack MM, Sapru A, Wessel D, Yates AR, Zuppa AF. Effect of Physiologic Point-of-Care Cardiopulmonary Resuscitation Training on Survival With Favorable Neurologic Outcome in Cardiac Arrest in Pediatric ICUs: A Randomized Clinical Trial. JAMA 2022; 327:934-945. [PMID: 35258533 PMCID: PMC8905390 DOI: 10.1001/jama.2022.1738] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
IMPORTANCE Approximately 40% of children who experience an in-hospital cardiac arrest survive to hospital discharge. Achieving threshold intra-arrest diastolic blood pressure (BP) targets during cardiopulmonary resuscitation (CPR) and systolic BP targets after the return of circulation may be associated with improved outcomes. OBJECTIVE To evaluate the effectiveness of a bundled intervention comprising physiologically focused CPR training at the point of care and structured clinical event debriefings. DESIGN, SETTING, AND PARTICIPANTS A parallel, hybrid stepped-wedge, cluster randomized trial (Improving Outcomes from Pediatric Cardiac Arrest-the ICU-Resuscitation Project [ICU-RESUS]) involving 18 pediatric intensive care units (ICUs) from 10 clinical sites in the US. In this hybrid trial, 2 clinical sites were randomized to remain in the intervention group and 2 in the control group for the duration of the study, and 6 were randomized to transition from the control condition to the intervention in a stepped-wedge fashion. The index (first) CPR events of 1129 pediatric ICU patients were included between October 1, 2016, and March 31, 2021, and were followed up to hospital discharge (final follow-up was April 30, 2021). INTERVENTION During the intervention period (n = 526 patients), a 2-part ICU resuscitation quality improvement bundle was implemented, consisting of CPR training at the point of care on a manikin (48 trainings/unit per month) and structured physiologically focused debriefings of cardiac arrest events (1 debriefing/unit per month). The control period (n = 548 patients) consisted of usual pediatric ICU management of cardiac arrest. MAIN OUTCOMES AND MEASURES The primary outcome was survival to hospital discharge with a favorable neurologic outcome defined as a Pediatric Cerebral Performance Category score of 1 to 3 or no change from baseline (score range, 1 [normal] to 6 [brain death or death]). The secondary outcome was survival to hospital discharge. RESULTS Among 1389 cardiac arrests experienced by 1276 patients, 1129 index CPR events (median patient age, 0.6 [IQR, 0.2-3.8] years; 499 girls [44%]) were included and 1074 were analyzed in the primary analysis. There was no significant difference in the primary outcome of survival to hospital discharge with favorable neurologic outcomes in the intervention group (53.8%) vs control (52.4%); risk difference (RD), 3.2% (95% CI, -4.6% to 11.4%); adjusted OR, 1.08 (95% CI, 0.76 to 1.53). There was also no significant difference in survival to hospital discharge in the intervention group (58.0%) vs control group (56.8%); RD, 1.6% (95% CI, -6.2% to 9.7%); adjusted OR, 1.03 (95% CI, 0.73 to 1.47). CONCLUSIONS AND RELEVANCE In this randomized clinical trial conducted in 18 pediatric intensive care units, a bundled intervention of cardiopulmonary resuscitation training at the point of care and physiologically focused structured debriefing, compared with usual care, did not significantly improve patient survival to hospital discharge with favorable neurologic outcome among pediatric patients who experienced cardiac arrest in the ICU. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02837497.
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Affiliation(s)
| | | | - Robert M Sutton
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Heather A Wolfe
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Tageldin Ahmed
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Robert Bishop
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew Bochkoris
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Candice Burns
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - J Wesley Diddle
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Myke Federman
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Richard Fernandez
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Deborah Franzon
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Aisha H Frazier
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Stuart H Friess
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Kathryn Graham
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - David Hehir
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Christopher M Horvat
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Leanna L Huard
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - William P Landis
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Tensing Maa
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Arushi Manga
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Ryan W Morgan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Chella A Palmer
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Carleen Schneiter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Matthew P Sharron
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Ashley Siems
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Neeraj Srivastava
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - Sarah Tabbutt
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Bradley Tilford
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Shirley Viteri
- Department of Pediatrics, Nemours/Alfred I. duPont Hospital for Children and Thomas Jefferson University, Wilmington, Delaware
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
| | - Michael J Bell
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Joseph A Carcillo
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ericka L Fink
- Department of Critical Care Medicine, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark Hall
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit
| | - Peter M Mourani
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora
| | - Daniel Notterman
- Department of Molecular Biology, Princeton University, Princeton, New Jersey
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California. Los Angeles
| | - David Wessel
- Department of Pediatrics, Children's National Hospital, George Washington University School of Medicine, Washington, DC
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia
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Tsitsiklis A, Osborne CM, Kamm J, Williamson K, Kalantar K, Dudas G, Caldera S, Lyden A, Tan M, Neff N, Soesanto V, Harris JK, Ambroggio L, Maddux AB, Carpenter TC, Reeder RW, Locandro C, Simões EAF, Leroue MK, Hall MW, Zuppa AF, Carcillo J, Meert KL, Sapru A, Pollack MM, McQuillen PS, Notterman DA, Dean JM, Zinter MS, Wagner BD, DeRisi JL, Mourani PM, Langelier CR. Lower respiratory tract infections in children requiring mechanical ventilation: a multicentre prospective surveillance study incorporating airway metagenomics. The Lancet Microbe 2022; 3:e284-e293. [PMID: 35544065 PMCID: PMC9446282 DOI: 10.1016/s2666-5247(21)00304-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alexandra Tsitsiklis
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA
| | - Christina M Osborne
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Kayla Williamson
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | | | - Gytis Dudas
- Gothenburg Global Biodiversity Centre, Gothenburg, Sweden
| | - Saharai Caldera
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Amy Lyden
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | | | - Norma Neff
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Victoria Soesanto
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Section of Pulmonary Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Section of Hospital Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Todd C Carpenter
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Chris Locandro
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Eric A F Simões
- Section of Infectious Diseases, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Matthew K Leroue
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Mark W Hall
- Department of Pediatrics, Division of Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Joseph Carcillo
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI, USA
| | - Anil Sapru
- Department of Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital and George Washington School of Medicine and Health Services, Washington, DC, USA
| | - Patrick S McQuillen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Matt S Zinter
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Brandie D Wagner
- Department of Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Joseph L DeRisi
- Department of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Peter M Mourani
- Section of Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA; Department of Pediatrics, Section of Critical Care Medicine, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, AR, USA
| | - Charles R Langelier
- Department of Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA; Chan Zuckerberg Biohub, San Francisco, CA, USA.
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Linakis JG, Thomas SA, Bromberg JR, Casper TC, Chun TH, Mello MJ, Richards R, Ahmad F, Bajaj L, Brown KM, Chernick LS, Cohen DM, Dean JM, Fein J, Horeczko T, Levas MN, McAninch B, Monuteaux MC, Mull CC, Grupp-Phelan J, Powell EC, Rogers A, Shenoi RP, Suffoletto B, Vance C, Spirito A. Adolescent alcohol use predicts cannabis use over a three year follow-up period. Subst Abus 2022; 43:514-519. [PMID: 34236277 PMCID: PMC8759759 DOI: 10.1080/08897077.2021.1949665] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Alcohol and cannabis use frequently co-occur, which can result in problems from social and academic impairment to dependence (i.e., alcohol use disorder [AUD] and/or cannabis use disorder [CUD]). The Emergency Department (ED) is an excellent site to identify adolescents with alcohol misuse, conduct a brief intervention, and refer to treatment; however, given time constraints, alcohol use may be the only substance assessed due to its common role in unintentional injury. The current study, a secondary data analysis, assessed the relationship between adolescent alcohol and cannabis use by examining the National Institute of Alcohol Abuse and Alcoholism (NIAAA) two question screen's (2QS) ability to predict future CUD at one, two, and three years post-ED visit. Methods: At baseline, data was collected via tablet self-report surveys from medically and behaviorally stable adolescents 12-17 years old (n = 1,689) treated in 16 pediatric EDs for non-life-threatening injury, illness, or mental health condition. Follow-up surveys were completed via telephone or web-based survey. Logistic regression compared CUD diagnosis odds at one, two, or three-year follow-up between levels constituting a single-level change in baseline risk categorization on the NIAAA 2QS (nondrinker versus low-risk, low- versus moderate-risk, moderate- versus high-risk). Receiver operating characteristic curve methods examined the predictive ability of the baseline NIAAA 2QS cut points for CUD at one, two, or three-year follow-up. Results: Adolescents with low alcohol risk had significantly higher rates of CUD versus nondrinkers (OR range: 1.94-2.76, p < .0001). For low and moderate alcohol risk, there was no difference in CUD rates (OR range: 1.00-1.08). CUD rates were higher in adolescents with high alcohol risk versus moderate risk (OR range: 2.39-4.81, p < .05). Conclusions: Even low levels of baseline alcohol use are associated with risk for a later CUD. The NIAAA 2QS is an appropriate assessment measure to gauge risk for future cannabis use.
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Affiliation(s)
| | | | - Julie R. Bromberg
- The Warren Alpert Medical School of Brown University;,Rhode Island Hospital
| | | | - Thomas H. Chun
- The Warren Alpert Medical School of Brown University;,Rhode Island Hospital
| | - Michael J. Mello
- The Warren Alpert Medical School of Brown University;,Rhode Island Hospital
| | | | - Fahd Ahmad
- St. Louis Children’s Hospital/ Washington University
| | | | | | | | | | | | - Joel Fein
- The Children’s Hospital of Philadelphia
| | - Timothy Horeczko
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center
| | | | - B McAninch
- University of Pittsburgh/ Children’s Hospital of Pittsburgh of UPMC
| | | | - Colette C. Mull
- Sidney Kimmel Medical College at Jefferson University/ Nemours Alfred I. duPont Hospital for Children
| | | | | | | | | | - Brian Suffoletto
- University of Pittsburgh/ Children’s Hospital of Pittsburgh of UPMC
| | | | - Anthony Spirito
- The Warren Alpert Medical School of Brown University;,Address correspondence to: Anthony Spirito, PhD, Alpert Medical School of Brown University, Department of Psychiatry and Human Behavior, Box G-BH, Providence, RI 02912, United States,
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36
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Muszynski JA, Banks R, Reeder RW, Hall MW, Berg RA, Zuppa A, Shanley TP, Cornell TT, Newth CJL, Pollack MM, Wessel D, Doctor A, Lin JC, Harrison RE, Meert KL, Dean JM, Holubkov R, Carcillo JA. Outcomes Associated With Early RBC Transfusion in Pediatric Severe Sepsis: A Propensity-Adjusted Multicenter Cohort Study. Shock 2022; 57:88-94. [PMID: 34628452 PMCID: PMC8678199 DOI: 10.1097/shk.0000000000001863] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Little is known about the epidemiology of and outcomes related to red blood cell (RBC) transfusion in septic children across multiple centers. We performed propensity-adjusted secondary analyses of the Biomarker Phenotyping of Pediatric Sepsis and Multiple Organ Failure (PHENOMS) study to test the hypothesis that early RBC transfusion is associated with fewer organ failure-free days in pediatric severe sepsis. METHODS Four hundred one children were enrolled in the parent study. Children were excluded from these analyses if they received extracorporeal membrane oxygenation (n = 22) or died (n = 1) before sepsis day 2. Propensity-adjusted analyses compared children who received RBC transfusion on or before sepsis day 2 (early RBC transfusion) with those who did not. Logistic regression was used to model the propensity to receive early RBC transfusion. A weighted cohort was constructed using stabilized inverse probability of treatment weights. Variables in the weighted cohort with absolute standardized differences >0.15 were added to final multivariable models. RESULTS Fifty percent of children received at least one RBC transfusion. The majority (68%) of first transfusions were on or before sepsis day 2. Early RBC transfusion was not independently associated with organ failure-free (-0.34 [95%CI: -2, 1.3] days) or PICU-free days (-0.63 [-2.3, 1.1]), but was associated with the secondary outcome of higher mortality (aOR 2.9 [1.1, 7.9]). CONCLUSIONS RBC transfusion is common in pediatric severe sepsis and may be associated with adverse outcomes. Future studies are needed to clarify these associations, to understand patient-specific transfusion risks, and to develop more precise transfusion strategies.
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Affiliation(s)
- Jennifer A Muszynski
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Mark W Hall
- Division of Critical Care, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
- Center for Clinical and Translational Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A Berg
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Athena Zuppa
- Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P Shanley
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Timothy T Cornell
- Department of Pediatrics, Mott Children's Hospital, Ann Arbor, Michigan
| | - Christopher J L Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Murray M Pollack
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - David Wessel
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia
| | - Allan Doctor
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - John C Lin
- Department of Pediatrics, Washington University at Saint Louis, Saint Louis, Missouri
| | - Rick E Harrison
- Department of Pediatrics, UCLA Mattel Children's Hospital, Los Angeles, California
| | - Kathleen L Meert
- Division of Critical Care, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, Michigan
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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37
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Kernan KF, Ghaloul-Gonzalez L, Vockley J, Lamb J, Hollingshead D, Chandran U, Sethi R, Park HJ, Berg RA, Wessel D, Pollack MM, Meert KL, Hall MW, Newth CJL, Lin JC, Doctor A, Shanley T, Cornell T, Harrison RE, Zuppa AF, Banks R, Reeder RW, Holubkov R, Notterman DA, Dean JM, Carcillo JA. Prevalence of Pathogenic and Potentially Pathogenic Inborn Error of Immunity Associated Variants in Children with Severe Sepsis. J Clin Immunol 2022; 42:350-364. [PMID: 34973142 PMCID: PMC8720168 DOI: 10.1007/s10875-021-01183-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/15/2021] [Indexed: 12/29/2022]
Abstract
Purpose Our understanding of inborn errors of immunity is increasing; however, their contribution to pediatric sepsis is unknown. Methods We used whole-exome sequencing (WES) to characterize variants in genes related to monogenic immunologic disorders in 330 children admitted to intensive care for severe sepsis. We defined candidate variants as rare variants classified as pathogenic or potentially pathogenic in QIAGEN’s Human Gene Mutation Database or novel null variants in a disease-consistent inheritance pattern. We investigated variant correlation with infection and inflammatory phenotype. Results More than one in two children overall and three of four African American children had immunodeficiency-associated variants. Children with variants had increased odds of isolating a blood or urinary pathogen (blood: OR 2.82, 95% CI: 1.12–7.10, p = 0.023, urine: OR: 8.23, 95% CI: 1.06–64.11, p = 0.016) and demonstrating increased inflammation with hyperferritinemia (ferritin \documentclass[12pt]{minimal}
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\begin{document}$$\ge 500$$\end{document}≥500 ng/mL, OR: 2.16, 95% CI: 1.28–3.66, p = 0.004), lymphopenia (lymphocyte count < 1000/µL, OR: 1.66, 95% CI: 1.06 – 2.60, p = 0.027), thrombocytopenia (platelet count < 150,000/µL, OR: 1.76, 95% CI: 1.12–2.76, p = 0.013), and CRP greater than 10 mg/dl (OR: 1.71, 95% CI: 1.10–2.68, p = 0.017). They also had increased odds of requiring extracorporeal membrane oxygenation (ECMO, OR: 4.19, 95% CI: 1.21–14.5, p = 0.019). Conclusion Herein, we describe the genetic findings in this severe pediatric sepsis cohort and their microbiologic and immunologic significance, providing evidence for the phenotypic effect of these variants and rationale for screening children with life-threatening infections for potential inborn errors of immunity. Supplementary Information The online version contains supplementary material available at 10.1007/s10875-021-01183-4.
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Affiliation(s)
- Kate F Kernan
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Lina Ghaloul-Gonzalez
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jerry Vockley
- Division of Genetic and Genomic Medicine, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
| | - Janette Lamb
- Genomics Core Laboratory, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Uma Chandran
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rahil Sethi
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, USA
| | - Hyun-Jung Park
- Department of Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - David Wessel
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Murray M Pollack
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Kathleen L Meert
- Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
- Central Michigan University, Mt. Pleasant, MI, USA
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, The Research Institute at Nationwide Children's Hospital Immune Surveillance Laboratory, and Nationwide Children's Hospital, Columbus, OH, USA
| | - Christopher J L Newth
- Division of Pediatric Critical Care Medicine, Department of Anesthesiology and Pediatrics, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Allan Doctor
- Division of Critical Care Medicine, Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
- Division of Pediatric Critical Care Medicine, The Center for Blood Oxygen Transport and Hemostasis, University of Maryland School of Medicine, MD, Baltimore, USA
| | - Tom Shanley
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Tim Cornell
- Division of Critical Care Medicine, Department of Pediatrics, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
- Department of Pediatrics, Lucile Packard Children's Hospital Stanford, Stanford University, CA, Palo Alto, USA
| | - Rick E Harrison
- Division of Critical Care Medicine, Department of Pediatrics, Mattel Children's Hospital at University of California Los Angeles, Los Angeles, CA, USA
| | - Athena F Zuppa
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Russel Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Ron W Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Joseph A Carcillo
- Division of Pediatric Critical Care Medicine, Department of Critical Care Medicine, Center for Critical Care Nephrology and Clinical Research Investigation and Systems Modeling of Acute Illness Center, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, USA
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Johnson AR, Rigtrup LM, VanBuren J, Rothwell E, Dean JM. An Approach to Reviewing Local Context for Exception from Informed Consent Trials Using a Single IRB. Ethics Hum Res 2021; 43:42-48. [PMID: 34751515 PMCID: PMC10353538 DOI: 10.1002/eahr.500109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
In the context of emergency research, researchers can ask the institutional review board (IRB) to waive the regulatory requirement that individuals provide informed consent when enrolling in research studies. A requirement of the waiver of informed consent is that the reviewing IRB must review and approve a community consultation and public disclosure plan. It is critical that an IRB serving as the single IRB (sIRB) for multisite research be thoroughly versed in the local context concerns for each participating site to determine whether the site's community is being adequately consulted about the research in which individuals will be enrolled under an exception to the informed consent requirement. We designed an sIRB review model for evaluating site-specific community consultation plans that included a local evaluation and feedback step, and we piloted the model with a four-site, pediatric exception from informed consent (EFIC) clinical trial. We identified three key roles for the model: the sIRB, the investigators, and the representative of the institution's human research protection program (HRPP). We successfully collected the information and local input needed to evaluate each site's community consultation plan and applied the information to a thorough IRB review, despite the geographic distance between the study site and the sIRB.
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Affiliation(s)
- Ann R Johnson
- Director of the institutional review board and Human Research Protection Program at the University of Utah
| | - Lisa M Rigtrup
- Manager of the institutional review board at the University of Utah
| | - John VanBuren
- Associate professor and statistician in the Department of Pediatrics at the University of Utah
| | - Erin Rothwell
- Professor and social scientist in the Department of Obstetrics and Gynecology at the University of Utah
| | - J Michael Dean
- Professor and vice chairman for research in the Department of Pediatrics at the University of Utah
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39
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VanBuren JM, Casper TC, Nishijima DK, Kuppermann N, Lewis RJ, Dean JM, McGlothlin A. The design of a Bayesian adaptive clinical trial of tranexamic acid in severely injured children. Trials 2021; 22:769. [PMID: 34736498 PMCID: PMC8567588 DOI: 10.1186/s13063-021-05737-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/20/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma is the leading cause of death and disability in children in the USA. Tranexamic acid (TXA) reduces the blood transfusion requirements in adults and children during surgery. Several studies have evaluated TXA in adults with hemorrhagic trauma, but no randomized controlled trials have occurred in children with trauma. We propose a Bayesian adaptive clinical trial to investigate TXA in children with brain and/or torso hemorrhagic trauma. METHODS/DESIGN We designed a double-blind, Bayesian adaptive clinical trial that will enroll up to 2000 patients. We extend the traditional Emax dose-response model to incorporate a hierarchical structure so multiple doses of TXA can be evaluated in different injury populations (isolated head injury, isolated torso injury, or both head and torso injury). Up to 3 doses of TXA (15 mg/kg, 30 mg/kg, and 45 mg/kg bolus doses) will be compared to placebo. Equal allocation between placebo, 15 mg/kg, and 30 mg/kg will be used for an initial period within each injury group. Depending on the dose-response curve, the 45 mg/kg arm may open in an injury group if there is a trend towards increasing efficacy based on the observed relationship using the data from the lower doses. Response-adaptive randomization allows each injury group to differ in allocation proportions of TXA so an optimal dose can be identified for each injury group. Frequent interim stopping periods are included to evaluate efficacy and futility. The statistical design is evaluated through extensive simulations to determine the operating characteristics in several plausible scenarios. This trial achieves adequate power in each injury group. DISCUSSION This trial design evaluating TXA in pediatric hemorrhagic trauma allows for three separate injury populations to be analyzed and compared within a single study framework. Individual conclusions regarding optimal dosing of TXA can be made within each injury group. Identifying the optimal dose of TXA, if any, for various injury types in childhood may reduce death and disability.
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Affiliation(s)
- John M. VanBuren
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - T. Charles Casper
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | - Daniel K. Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA 95817 USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA 95817 USA
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA 95817 USA
| | - Roger J. Lewis
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509 USA
- Berry Consultants, LLC, Austin, TX 78746 USA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
| | | | - For the TIC-TOC Collaborators of the Pediatric Emergency Care Applied Research Network (PECARN)
- Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108 USA
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA 95817 USA
- Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA 95817 USA
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA 90509 USA
- Berry Consultants, LLC, Austin, TX 78746 USA
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Burd RS, Jensen AR, VanBuren JM, Richards R, Holubkov R, Pollack MM, Berg RA, Carcillo JA, Carpenter TC, Dean JM, Gaines B, Hall MW, McQuillen PS, Meert KL, Mourani PM, Nance ML, Yates AR. Factors Associated With Functional Impairment After Pediatric Injury. JAMA Surg 2021; 156:e212058. [PMID: 34076684 DOI: 10.1001/jamasurg.2021.2058] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Short- and long-term functional impairment after pediatric injury may be more sensitive for measuring quality of care compared with mortality alone. The characteristics of injured children and adolescents who are at the highest risk for functional impairment are unknown. Objective To evaluate categories of injuries associated with higher prevalence of impaired functional status at hospital discharge among children and adolescents and to estimate the number of those with injuries in these categories who received treatment at pediatric trauma centers. Design, Setting, and Participants This prospective cohort study (Assessment of Functional Outcomes and Health-Related Quality of Life After Pediatric Trauma) included children and adolescents younger than 15 years who were hospitalized with at least 1 serious injury at 1 of 7 level 1 pediatric trauma centers from March 2018 to February 2020. Exposure At least 1 serious injury (Abbreviated Injury Scale score, ≥3 [scores range from 1 to 6, with higher scores indicating more severe injury]) classified into 9 categories based on the body region injured and the presence of a severe traumatic brain injury (Glasgow Coma Scale score <9 or Glasgow Coma Scale motor score <5). Main Outcomes and Measures New domain morbidity defined as a 2 points or more change in any of 6 domains (mental status, sensory, communication, motor function, feeding, and respiratory) measured using the Functional Status Scale (FSS) (scores range from 1 [normal] to 5 [very severe dysfunction] for each domain) in each injury category at hospital discharge. The estimated prevalence of impairment associated with each injury category was assessed in the population of seriously injured children and adolescents treated at participating sites. Results This study included a sample of 427 injured children and adolescents (271 [63.5%] male; median age, 7.2 years [interquartile range, 2.5-11.7 years]), 74 (17.3%) of whom had new FSS domain morbidity at discharge. The proportion of new FSS domain morbidity was highest among those with multiple injured body regions and severe head injury (20 of 24 [83.3%]) and lowest among those with an isolated head injury of mild or moderate severity (1 of 84 [1.2%]). After adjusting for oversampling of specific injuries in the study sample, 749 of 5195 seriously injured children and adolescents (14.4%) were estimated to have functional impairment at hospital discharge. Children and adolescents with extremity injuries (302 of 749 [40.3%]) and those with severe traumatic brain injuries (258 of 749 [34.4%]) comprised the largest proportions of those estimated to have impairment at discharge. Conclusions and Relevance In this cohort study, most injured children and adolescents returned to baseline functional status by hospital discharge. These findings suggest that functional status assessments can be limited to cohorts of injured children and adolescents at the highest risk for impairment.
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Affiliation(s)
- Randall S Burd
- Division of Trauma and Burn Surgery, Children's National Medical Center, Washington, DC
| | - Aaron R Jensen
- University of California San Francisco Benioff Children's Hospital Oakland, Oakland
| | - John M VanBuren
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Rachel Richards
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Murray M Pollack
- Department of Pediatrics, Children's National Health System and the George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Robert A Berg
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Joseph A Carcillo
- Department of Critical Care Medicine and Pediatrics, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd C Carpenter
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora
| | - J Michael Dean
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Barbara Gaines
- Division of Pediatric General and Thoracic Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark W Hall
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit.,Central Michigan University, Mt Pleasant
| | - Peter M Mourani
- Arkansas Children's Research Institute, Arkansas Children's Hospital, Little Rock
| | - Michael L Nance
- Division of Pediatric Trauma, Department of Surgery, College of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew R Yates
- Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus
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Siems A, Banks R, Holubkov R, Meert KL, Bauerfeld C, Beyda D, Berg RA, Bulut Y, Burd RS, Carcillo J, Dean JM, Gradidge E, Hall MW, McQuillen PS, Mourani PM, Newth CJL, Notterman DA, Priestley MA, Sapru A, Wessel DL, Yates AR, Zuppa AF, Pollack MM. Structured Chart Review: Assessment of a Structured Chart Review Methodology. Hosp Pediatr 2021; 10:61-69. [PMID: 31879317 DOI: 10.1542/hpeds.2019-0225] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Chart reviews are frequently used for research, care assessments, and quality improvement activities despite an absence of data on reliability and validity. We aim to describe a structured chart review methodology and to establish its validity and reliability. METHODS A generalizable structured chart review methodology was designed to evaluate causes of morbidity or mortality and to identify potential therapeutic advances. The review process consisted of a 2-tiered approach with a primary review completed by a site physician and a short secondary review completed by a central physician. A total of 327 randomly selected cases of known mortality or new morbidities were reviewed. Validity was assessed by using postreview surveys with a Likert scale. Reliability was assessed by percent agreement and interrater reliability. RESULTS The primary reviewers agreed or strongly agreed in 94.9% of reviews that the information to form a conclusion about pathophysiological processes and therapeutic advances could be adequately found. They agreed or strongly agreed in 93.2% of the reviews that conclusions were easy to make, and confidence in the process was 94.2%. Secondary reviewers made modifications to 36.6% of cases. Duplicate reviews (n = 41) revealed excellent percent agreement for the causes (80.5%-100%) and therapeutic advances (68.3%-100%). κ statistics were strong for the pathophysiological categories but weaker for the therapeutic categories. CONCLUSIONS A structured chart review by knowledgeable primary reviewers, followed by a brief secondary review, can be valid and reliable.
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Affiliation(s)
- Ashley Siems
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Russell Banks
- School of Medicine, University of Utah, Salt Lake City, Utah
| | | | - Kathleen L Meert
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - Christian Bauerfeld
- Wayne State University and Children's Hospital of Michigan, Detroit, Michigan
| | - David Beyda
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Robert A Berg
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Yonca Bulut
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - Randall S Burd
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | - Joseph Carcillo
- University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - J Michael Dean
- School of Medicine, University of Utah, Salt Lake City, Utah
| | - Eleanor Gradidge
- College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Mark W Hall
- Nationwide Children's Hospital, Columbus, Ohio
| | - Patrick S McQuillen
- University of California, San Francisco and University of California, San Francisco Benioff Children's Hospital, San Francisco, California
| | - Peter M Mourani
- University of Colorado and Children's Hospital of Colorado, Denver, Colorado
| | - Christopher J L Newth
- Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California; and
| | | | | | - Anil Sapru
- University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, California
| | - David L Wessel
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia
| | | | - Athena F Zuppa
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Murray M Pollack
- School of Medicine and Health Sciences, The George Washington University and Children's National Health System, Washington, District of Columbia;
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. Complicated Grief, Depression and Post-Traumatic Stress Symptoms Among Bereaved Parents following their Child's Death in the Pediatric Intensive Care Unit: A Follow-Up Study. Am J Hosp Palliat Care 2021; 39:228-236. [PMID: 33949217 PMCID: PMC10184266 DOI: 10.1177/10499091211015913] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Parents often suffer reduced mental health after their child's death; however, the trajectory and risk factors are not well described. OBJECTIVE Describe the change in complicated grief, depression, and post-traumatic stress symptoms among parents between 6 and 13 months after their child's death in a pediatric intensive care unit (PICU), and factors associated with 13-month symptoms. METHODS Parents whose children died in 1 of 8 PICUs affiliated with the Collaborative Pediatric Critical Care Research Network completed surveys 6 and 13 months after their child's death. Surveys included the Inventory of Complicated Grief (ICG), the Patient Health Questionnaire-8 (PHQ-8) for depression, and the Short Post-Traumatic Stress Disorder Rating Interview (SPRINT). Parents provided sociodemographics. Charts were reviewed for child characteristics. RESULTS One-hundred and fifty seven parents of 104 deceased children completed surveys at both time points. Mental health symptoms declined over time (mean (SD)): ICG (33.8 (15.4) vs. 30.5 (15.2), p < 0.001), PHQ-8 (9.0 (6.4) vs. 7.3 (5.8), p < 0.001), and SPRINT (14.1 (8.3) vs. 12.0 (8.2), p < 0.001). After controlling for 6-month scores, higher 13-month ICG was independently associated with sudden unexpected death; higher PHQ-8 with Black race, insecure attachment style, and sudden unexpected death; and higher SPRINT with having a high school level of education (compared to college degree or higher). CONCLUSION Mental health symptoms improve among parents during the first 13 months after their child's death; however, symptoms persist for many. Black parents and those whose children die suddenly may be high risk for poor adjustment during bereavement.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA)
| | - Mark W Hall
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA)
| | - Murray M Pollack
- Department of Pediatrics, Children's National Hospital, Washington DC, USA
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick S McQuillen
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, CA, USA
| | - Peter M Mourani
- Department of Pediatrics, Children's Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Anil Sapru
- Department of Pediatrics, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Daniel A Notterman
- Department of Molecular Biology, Princeton University, Princeton, NJ, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, Central Michigan University, Mt. Pleasant, MI, USA
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Meert KL, Reeder RW, Maddux AB, Banks R, Berg RA, Newth CJ, Hall MW, Quasney M, Carcillo JA, McQuillen PS, Mourani PM, Chima RS, Holubkov R, Sorenson S, McGalliard J, Dean JM, Zimmerman JJ. Health-Related Quality of Life After Community-Acquired Septic Shock in Children With Preexisting Severe Developmental Disabilities. Pediatr Crit Care Med 2021; 22:e302-e313. [PMID: 33156209 PMCID: PMC8099927 DOI: 10.1097/pcc.0000000000002606] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Indexed: 01/15/2023]
Abstract
OBJECTIVES To serially evaluate health-related quality of life during the first year after community-acquired septic shock in children with preexisting severe developmental disabilities and explore factors associated with health-related quality of life changes in these children. DESIGN Secondary analysis of the Life after Pediatric Sepsis Evaluation investigation. SETTING Twelve academic PICU in the United States. PATIENTS Children greater than or equal to 1 month and less than 18 years old identified by their family caregiver (e.g., parent/guardian) as having severe developmental disability prior to septic shock. INTERVENTIONS Family caregivers completed the Stein-Jessop Functional Status II-R Short Form as a measure of their child's health-related quality of life at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Stein-Jessop Functional Status II-R Short Form scores were linearly transformed to a 0-100 scale, with higher scores indicating better health-related quality of life. MEASUREMENTS AND MAIN RESULTS Of 392 Life after Pediatric Sepsis Evaluation participants, 137 were identified by their caregiver as having a severe developmental disability. Sixteen children (11.6%) with severe disability died during the 12 months following septic shock. Among 121 survivors, Stein-Jessop Functional Status II-R Short Form scores declined from preadmission baseline to day 7 (70.7 ± 16.1 vs 55.6 ± 19.2; p < 0.001). Stein-Jessop Functional Status II-R Short Form scores remained below baseline through month 12 (59.1 ± 21.0, p < 0.001 vs baseline). After adjusting for baseline Stein-Jessop Functional Status II-R Short Form, the caregiver being a single parent/guardian was associated with lower month 3 Stein-Jessop Functional Status II-R Short Form scores (p = 0.041). No other baseline child or caregiver characteristic, or critical illness-related factors were significantly associated with month 3 Stein-Jessop Functional Status II-R Short Form scores. CONCLUSIONS Health-related quality of life among children with severe developmental disability remains, on average, below baseline during the first year following community-acquired septic shock. Children with severe disability and septic shock that are in single parent families are at increased risk. Clinical awareness of the potential for decline in health-related quality of life among disabled children is essential to prevent this adverse outcome from being missed.
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Affiliation(s)
- Kathleen L. Meert
- Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University, Detroit, MI
| | - Ron W. Reeder
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aline B. Maddux
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Russell Banks
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J. Newth
- Department of Anesthesiology Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, CA
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Michael Quasney
- Department of Pediatrics, C.S. Mott Children’s Hospital, University of Michigan, Ann Arbor, MI
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M. Mourani
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Ranjit S. Chima
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Samuel Sorenson
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Julie McGalliard
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle Research Institute, Seattle, WA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Jerry J. Zimmerman
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA
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King CA, Brent D, Grupp-Phelan J, Casper TC, Dean JM, Chernick LS, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange M, Rogers A, Cohen DM, Keller A, Shenoi R, Hickey RW, Rea M, Cwik M, Page K, McGuire TC, Wang J, Gibbons R. Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA Psychiatry 2021; 78:540-549. [PMID: 33533908 PMCID: PMC7859874 DOI: 10.1001/jamapsychiatry.2020.4576] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services. OBJECTIVE To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTS Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts. EXPOSURES Presentation at an ED. MAIN OUTCOME AND MEASURE A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report. RESULTS The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1. CONCLUSIONS AND RELEVANCE In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.
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Affiliation(s)
- Cheryl A. King
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - David Brent
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | - Lauren S. Chernick
- Department of Emergency Medicine and Pediatrics, Columbia University Medical Center, New York, New York
| | - Joel A. Fein
- Center for Violence Prevention, Children’s Hospital of Philadelphia, Division of Emergency Medicine, University of Pennsylvania, Philadelphia
| | | | - Shilpa J. Patel
- Division of Emergency Medicine, Children’s National Hospital, Washington, DC
| | - Rakesh D. Mistry
- Department of Pediatrics–Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Susan Duffy
- Department of Emergency Medicine, Alpert Medical School at Brown University, Providence, Rhode Island,Department of Pediatrics, Alpert Medical School at Brown University, Providence, Rhode Island
| | | | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor,Department of Pediatrics, University of Michigan, Ann Arbor
| | - Daniel M. Cohen
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Allison Keller
- Department of Pediatric Emergency Medicine, The University of Utah, Salt Lake City
| | - Rohit Shenoi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Robert W. Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Margaret Rea
- Medical Center at the University of California School of Medicine, Davis, Sacramento
| | - Mary Cwik
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kent Page
- The University of Utah School of Medicine, Salt Lake City
| | | | - Jiebiao Wang
- Department of Statistics and Data Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Robert Gibbons
- Department of Medicine, The University of Chicago, Chicago, Illinois,Department of Public Health Sciences (Biostatistics), The University of Chicago, Chicago, Illinois,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois,Department of Comparative Human Development, The University of Chicago, Chicago, Illinois
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Greenberg RG, Poole L, Ford DE, Hanley D, Selker HP, Lane K, Dean JM, Burr J, Harris P, Wilkins CH, Bernard G, Edwards T, Benjamin DK. Response of the trial innovation network to the COVID-19 pandemic. J Clin Transl Sci 2021; 5:e100. [PMID: 34192055 PMCID: PMC8185427 DOI: 10.1017/cts.2021.782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 12/28/2020] [Revised: 04/11/2021] [Accepted: 04/13/2021] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION The COVID-19 pandemic prompted the development and implementation of hundreds of clinical trials across the USA. The Trial Innovation Network (TIN), funded by the National Center for Advancing Translational Sciences, was an established clinical research network that pivoted to respond to the pandemic. METHODS The TIN's three Trial Innovation Centers, Recruitment Innovation Center, and 66 Clinical and Translational Science Award Hub institutions, collaborated to adapt to the pandemic's rapidly changing landscape, playing central roles in the planning and execution of pivotal studies addressing COVID-19. Our objective was to summarize the results of these collaborations and lessons learned. RESULTS The TIN provided 29 COVID-related consults between March 2020 and December 2020, including 6 trial participation expressions of interest and 8 community engagement studios from the Recruitment Innovation Center. Key lessons learned from these experiences include the benefits of leveraging an established infrastructure, innovations surrounding remote research activities, data harmonization and central safety reviews, and early community engagement and involvement. CONCLUSIONS Our experience highlighted the benefits and challenges of a multi-institutional approach to clinical research during a pandemic.
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Affiliation(s)
| | - Lori Poole
- Duke Clinical Research Institute, Durham, NC, USA
| | | | | | | | - Karen Lane
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Jeri Burr
- University of Utah, Salt Lake City, UT, USA
| | - Paul Harris
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Consuelo H. Wilkins
- Vanderbilt University Medical Center, Nashville, TN, USA
- Meharry Medical College, Nashville, TN, USA
| | - Gordon Bernard
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Terri Edwards
- Vanderbilt University Medical Center, Nashville, TN, USA
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Suttle M, Hall MW, Pollack MM, Berg RA, McQuillen PS, Mourani PM, Sapru A, Carcillo JA, Startup E, Holubkov R, Dean JM, Notterman DA, Meert KL. Therapeutic Alliance Between Bereaved Parents and Physicians in the PICU. Pediatr Crit Care Med 2021; 22:e243-e252. [PMID: 33044415 PMCID: PMC8016694 DOI: 10.1097/pcc.0000000000002585] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Therapeutic alliance is the collaborative bond that develops between patients/families and healthcare providers. Our objective is to determine the extent of therapeutic alliance bereaved parents perceive to have occurred with their child's physicians during their child's PICU stay, and associated factors. DESIGN Multicenter observational study. SETTING Eight children's hospitals affiliated with the Collaborative Pediatric Critical Care Research Network. PATIENTS Parents greater than or equal to 18 years old whose child died in a PICU (including cardiac ICU). INTERVENTIONS Bereaved parents completed the Human Connection Scale, a 16-item measure of therapeutic alliance, 6 months after their child's death. Human Connection Scale scores range from 16 to 64 with higher scores indicating greater alliance. Parents provided sociodemographic data, and medical records were reviewed for the child's clinical characteristics. MEASUREMENTS AND MAIN RESULTS Two-hundred and thirty-three parents of 157 deceased children responded to the Human Connection Scale with greater than or equal to 80% item completion. Among parents, 146 (62.7%) were female, 155 (66.5%) were White and 46 (19.7%) were Black, 175 (75.1%) were married, and 209 (89.7%) had at least a high-school education. Among children, median age at the time of death was 5.9 years (interquartile range, 0.64-13.9 yr) and 114 (72.6%) died after limitation or withdrawal of life support. Mean Human Connection Scale score was 51.4 ± 11.1 for all parents, 52.6 ± 9.0 for White parents, and 47.0 ± 13.7 for Black parents. In multivariable modeling predicting Human Connection Scale scores, race was the only parent or child characteristic in the final model. Human Connection Scale scores were significantly different (-4.56; 95% CI, -8.53 to -0.6; p = 0.025) between the Black and White parents with items about trust, care, and honest communication showing the greatest mean difference. CONCLUSIONS Among parents bereaved in the PICU, therapeutic alliance with physicians is moderately high. Future research should identify strategies to strengthen therapeutic alliance with Black parents and examine the role of alliance on bereaved parents' health outcomes.
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Affiliation(s)
- Markita Suttle
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Mark W. Hall
- Department of Pediatrics, Nationwide Children’s Hospital, Columbus, OH
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington DC
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Patrick S. McQuillen
- Department of Pediatrics, Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Peter M. Mourani
- Department of Pediatrics, Children’s Hospital of Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Anil Sapru
- Department of Pediatrics, Mattel Children’s Hospital, University of California Los Angeles, Los Angeles, CA
| | - Joseph A. Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Emily Startup
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Central Michigan University, Detroit, MI
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47
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Mourani PM, Sontag MK, Williamson KM, Harris JK, Reeder R, Locandro C, Carpenter TC, Maddux AB, Ziegler K, Simões EAF, Osborne CM, Ambroggio L, Leroue MK, Robertson CE, Langelier C, DeRisi JL, Kamm J, Hall MW, Zuppa AF, Carcillo J, Meert K, Sapru A, Pollack MM, McQuillen P, Notterman DA, Dean JM, Wagner BD. Temporal airway microbiome changes related to ventilator-associated pneumonia in children. Eur Respir J 2021; 57:13993003.01829-2020. [PMID: 33008935 DOI: 10.1183/13993003.01829-2020] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 09/02/2020] [Indexed: 12/27/2022]
Abstract
We sought to determine whether temporal changes in the lower airway microbiome are associated with ventilator-associated pneumonia (VAP) in children.Using a multicentre prospective study of children aged 31 days to 18 years requiring mechanical ventilation support for >72 h, daily tracheal aspirates were collected and analysed by sequencing of the 16S rRNA gene. VAP was assessed using 2008 Centers for Disease Control and Prevention paediatric criteria. The association between microbial factors and VAP was evaluated using joint longitudinal time-to-event modelling, matched case-control comparisons and unsupervised clustering.Out of 366 eligible subjects, 66 (15%) developed VAP at a median of 5 (interquartile range 3-5) days post intubation. At intubation, there was no difference in total bacterial load (TBL), but Shannon diversity and the relative abundance of Streptococcus, Lactobacillales and Prevotella were lower for VAP subjects versus non-VAP subjects. However, higher TBL on each sequential day was associated with a lower hazard (hazard ratio 0.39, 95% CI 0.23-0.64) for developing VAP, but sequential values of diversity were not associated with VAP. Similar findings were observed from the matched analysis and unsupervised clustering. The most common dominant VAP pathogens included Prevotella species (19%), Pseudomonas aeruginosa (14%) and Streptococcus mitis/pneumoniae (10%). Mycoplasma and Ureaplasma were also identified as dominant organisms in several subjects.In mechanically ventilated children, changes over time in microbial factors were marginally associated with VAP risk, although these changes were not suitable for predicting VAP in individual patients. These findings suggest that focusing exclusively on pathogen burden may not adequately inform VAP diagnosis.
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Affiliation(s)
- Peter M Mourani
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Marci K Sontag
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Kayla M Williamson
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - J Kirk Harris
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Ron Reeder
- Pediatrics, University of Utah, Salt Lake City, UT, USA
| | | | - Todd C Carpenter
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Aline B Maddux
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Katherine Ziegler
- Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Eric A F Simões
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Christina M Osborne
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Lilliam Ambroggio
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA.,Epidemiology, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
| | - Matthew K Leroue
- Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles E Robertson
- Medicine, Division of Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Charles Langelier
- Medicine, Division of Infectious Diseases, University of California San Francisco, San Francisco, CA, USA.,Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Joseph L DeRisi
- Chan Zuckerberg Biohub, San Francisco, CA, USA.,Dept of Biochemistry and Biophysics, University of California San Francisco, San Francisco, CA, USA
| | - Jack Kamm
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Mark W Hall
- Dept of Pediatrics, Nationwide Children's Hospital, Columbus, OH, USA
| | - Athena F Zuppa
- Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Kathleen Meert
- Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Anil Sapru
- Pediatrics, University of California Los Angeles, Los Angeles, CA, USA
| | - Murray M Pollack
- Pediatrics, Children's National Medical Center and George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Patrick McQuillen
- Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | | | | | - Brandie D Wagner
- Biostatistics and Informatics, University of Colorado, Colorado School of Public Health, Aurora, CO, USA
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48
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Workman JK, Bailly DK, Reeder RW, Dalton HJ, Berg RA, Shanley TP, Newth CJL, Pollack MM, Wessel D, Carcillo J, Harrison R, Dean JM, Meert KL. Risk Factors for Mortality in Refractory Pediatric Septic Shock Supported with Extracorporeal Life Support. ASAIO J 2021; 66:1152-1160. [PMID: 33136603 PMCID: PMC7773130 DOI: 10.1097/mat.0000000000001147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Risk factors for mortality in children with refractory pediatric septic shock who are supported with extracorporeal life support (ECLS) are largely unknown. Therefore, we performed univariable and multivariable analyses to determine risk factors for mortality among children (<19 years) who underwent an ECLS run between January 2012 and September 2014 at eight tertiary pediatric hospitals, and who had septic shock based on 2005 International Consensus Criteria. Of the 514 children treated with ECLS during the study period, 70 were identified with septic shock. The mortality rate was similar between those with (54.3%) and without septic shock (43.7%). Among those with septic shock, significant risk factors for mortality included cardiac failure or extracorporeal cardiopulmonary resuscitation (ECPR) as indication for ECLS cannulation compared with respiratory failure (P = 0.003), having a new neurologic event following cannulation (P = 0.032), acquiring a new infection following cannulation (P = 0.005), inability to normalize pH in the 48 hours following ECLS cannulation (P = 0.010), and requiring higher daily volume of platelet transfusions (P = 0.005). These findings can be used to help guide clinical decision making for children with septic shock that is refractory to medical management.
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Affiliation(s)
- Jennifer K. Workman
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - David K. Bailly
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Ron W. Reeder
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Heidi J. Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Falls Church, Virginia
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Thomas P. Shanley
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christopher J. L. Newth
- Department of Anesthesiology and Critical Care Medicine, Children’s Hospital Los Angeles, Los Angeles, California
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital and George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Rick Harrison
- Department of Pediatrics, University of Califronia, Mattel Children’s Hospital, Los Angeles, California
| | - J. Michael Dean
- Department of Pediatrics, Division of Critical Care, University of Utah, Salt Lake City, Utah
| | - Kathleen L. Meert
- Division of Critical Care, Department of Pediatrics, Children’s Hospital of Michigan/Wayne State University, Detroit, Michigan
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49
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Marrouche NF, Greene T, Dean JM, Kholmovski EG, Boer LMD, Mansour M, Calkins H, Marchlinski F, Wilber D, Hindricks G, Mahnkopf C, Jais P, Sanders P, Brachmann J, Bax J, Dagher L, Wazni O, Akoum N. Efficacy of LGE-MRI-guided fibrosis ablation versus conventional catheter ablation of atrial fibrillation: The DECAAF II trial: Study design. J Cardiovasc Electrophysiol 2021; 32:916-924. [PMID: 33600025 DOI: 10.1111/jce.14957] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [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] [Received: 01/30/2021] [Revised: 02/05/2021] [Accepted: 02/09/2021] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes. METHODS The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3-12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day postablation blanking period. Patients were followed for a period of 12-18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint. RESULTS AND CONCLUSION The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden.
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Affiliation(s)
- Nassir F Marrouche
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Tom Greene
- University of Utah, Salt Lake City, Utah, USA
| | | | | | | | - Moussa Mansour
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hugh Calkins
- Department of Cardiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Francis Marchlinski
- Department of Cardiology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - David Wilber
- Department of Cardiology, Loyola University Medical Center, Chicago, Illinois, USA
| | | | | | - Pierre Jais
- Department of Cardiology, Segalen University, Bordeaux, France
| | - Prashanthan Sanders
- Department of Cardiology, Centre for Heart Rhythm Disorders, Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | | | - Jereon Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lilas Dagher
- Department of Cardiology, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Oussama Wazni
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nazem Akoum
- Department of Cardiology, University of Washington Medical Center, Seattle, Washington, USA
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50
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Schnadower D, Sapien RE, Casper TC, Vance C, Tarr PI, O'Connell KJ, Levine AC, Roskind CG, Rogers AJ, Bhatt SR, Mahajan P, Powell EC, Olsen CS, Gorelick MH, Dean JM, Freedman SB. Association between Age, Weight, and Dose and Clinical Response to Probiotics in Children with Acute Gastroenteritis. J Nutr 2021; 151:65-72. [PMID: 33274370 PMCID: PMC7779240 DOI: 10.1093/jn/nxaa313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/25/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Gastroenteritis is a common and impactful disease in childhood. Probiotics are often used to treat acute gastroenteritis (AGE); however, in a large multicenter randomized controlled trial (RCT) in 971 children, Lactobacillus rhamnosus GG (LGG) was no better than placebo in improving patient outcomes. OBJECTIVES We sought to determine whether the effect of LGG is associated with age, weight z score and weight percentile adjusted for age and sex, or dose per kilogram administered. METHODS This was a preplanned secondary analysis of a multicenter double-blind RCT of LGG 1 × 1010 CFU twice daily for 5 d or placebo in children 3-48 mo of age with AGE. Our primary outcome was moderate to severe gastroenteritis. Secondary outcomes included diarrhea and vomiting frequency and duration, chronic diarrhea, and side effects. We used multivariable linear and nonlinear models testing for interaction effects to assess outcomes by age, weight z score and weight percentile adjusted for age and sex, and dose per kilogram of LGG received. RESULTS A total of 813 children (84%) were included in the analysis; 413 received placebo and 400 LGG. Baseline characteristics were similar between treatment groups. There were no differential interaction effects across ranges of age (P-interaction = 0.32), adjusted weight z score (P-interaction = 0.43), adjusted weight percentile (P-interaction = 0.45), or dose per kilogram of LGG received (P-interaction = 0.28) for the primary outcome. Whereas we found a statistical association favoring placebo at the extremes of adjusted weight z scores for the number of vomiting episodes (P-interaction = 0.02) and vomiting duration (P-interaction = 0.0475), there were no statistically significant differences in other secondary outcome measures (all P-interactions > 0.05). CONCLUSIONS LGG does not improve outcomes in children with AGE regardless of the age, adjusted weight z score, and adjusted weight percentile of participants, or the probiotic dose per kilogram received. These results further strengthen the conclusions of low risk of bias clinical trials which demonstrate that LGG provides no clinical benefit in children with AGE.This trial was registered at clinicaltrials.gov as NCT01773967.
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Affiliation(s)
- David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Health System, Department of Pediatrics and Emergency Medicine, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Adam C Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence, RI, USA
| | - Cindy G Roskind
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Seema R Bhatt
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth C Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cody S Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Marc H Gorelick
- Central Administration, Children's Minnesota, Minneapolis, MN, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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