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Podkovik S, Zhou C, Coffin SE, Hall M, Hauptman JS, Kronman MP, Mangano FT, Pollack IF, Sedano S, Vega J, Schaffzin JK, Thorell E, Warf BC, Whitlock KB, Simon TD. Antibiotic impregnated catheters and intrathecal antibiotics for CSF shunt infection prevention in children undergoing low-risk CSF shunt surgery. BMC Pediatr 2024; 24:325. [PMID: 38734598 DOI: 10.1186/s12887-024-04798-9] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 04/29/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND Cerebrospinal fluid (CSF) shunts allow children with hydrocephalus to survive and avoid brain injury (J Neurosurg 107:345-57, 2007; Childs Nerv Syst 12:192-9, 1996). The Hydrocephalus Clinical Research Network implemented non-randomized quality improvement protocols that were shown to decrease infection rates compared to pre-operative prophylactic intravenous antibiotics alone (standard care): initially with intrathecal (IT) antibiotics between 2007-2009 (J Neurosurg Pediatr 8:22-9, 2011), followed by antibiotic impregnated catheters (AIC) in 2012-2013 (J Neurosurg Pediatr 17:391-6, 2016). No large scale studies have compared infection prevention between the techniques in children. Our objectives were to compare the risk of infection following the use of IT antibiotics, AIC, and standard care during low-risk CSF shunt surgery (i.e., initial CSF shunt placement and revisions) in children. METHODS A retrospective observational cohort study at 6 tertiary care children's hospitals was conducted using Pediatric Health Information System + (PHIS +) data augmented with manual chart review. The study population included children ≤ 18 years who underwent initial shunt placement between 01/2007 and 12/2012. Infection and subsequent CSF shunt surgery data were collected through 12/2015. Propensity score adjustment for regression analysis was developed based on site, procedure type, and year; surgeon was treated as a random effect. RESULTS A total of 1723 children underwent initial shunt placement between 2007-2012, with 1371 subsequent shunt revisions and 138 shunt infections. Propensity adjusted regression demonstrated no statistically significant difference in odds of shunt infection between IT antibiotics (OR 1.22, 95% CI 0.82-1.81, p = 0.3) and AICs (OR 0.91, 95% CI 0.56-1.49, p = 0.7) compared to standard care. CONCLUSION In a large, observational multicenter cohort, IT antibiotics and AICs do not confer a statistically significant risk reduction compared to standard care for pediatric patients undergoing low-risk (i.e., initial or revision) shunt surgeries.
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Affiliation(s)
- Stacey Podkovik
- Department of Neurological Surgery, Riverside University Health Sciences Medical Center, Riverside, CA, USA
| | - Chuan Zhou
- Center for Child Health, Seattle Children's Research Institute, Behavior, and Development, Seattle, WA, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
| | - Susan E Coffin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Matthew Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Jason S Hauptman
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Matthew P Kronman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, WA, USA
| | - Francesco T Mangano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Ian F Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sabrina Sedano
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd,, MS 94, Los Angeles, CA, 90027, USA
| | - Joaquin Vega
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd,, MS 94, Los Angeles, CA, 90027, USA
| | | | - Emily Thorell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Harvard School of Medicine, Boston, MA, USA
| | | | - Tamara D Simon
- Division of Hospital Medicine, Children's Hospital Los Angeles, 4650 Sunset Blvd,, MS 94, Los Angeles, CA, 90027, USA.
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
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Podkovik S, Zhou C, Coffin SE, Hall M, Hauptman JS, Kronman MP, Mangano FT, Pollack IF, Sedano S, Schaffzin JK, Thorell E, Warf BC, Whitlock KB, Simon TD. Utilization trends in cerebrospinal fluid shunt infection prevention techniques in the United States from 2007 to 2015. J Neurosurg Pediatr 2024; 33:349-358. [PMID: 38181501 PMCID: PMC10810681 DOI: 10.3171/2023.11.peds2337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 11/03/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE The objective of this study was to describe trends in the utilization of infection prevention techniques (standard care, intrathecal [IT] antibiotics, antibiotic-impregnated catheters [AICs], and combination of IT antibiotics and AICs) among participating hospitals over time. METHODS This retrospective cohort study at six large children's hospitals between 2007 and 2015 included children ≤ 18 years of age who underwent initial shunt placement between 2007 and 2012. Pediatric Health Information System + (PHIS+) data were augmented with chart review data for all shunt surgeries that occurred prior to the first shunt infection. The Pearson chi-square test was used to test for differences in outcomes. RESULTS In total, 1723 eligible children had initial shunt placement between 2007 and 2012, with 3094 shunt surgeries through 2015. Differences were noted between hospitals in gestational age, etiology of hydrocephalus, and race and ethnicity, but not sex, weight at surgery, and previous surgeries. Utilization of infection prevention techniques varied across participating hospitals. Hydrocephalus Clinical Research Network hospitals used more IT antibiotics in 2007-2011; after 2012, increasing adoption of AICs was observed in most hospitals. CONCLUSIONS A consistent trend of decreasing IT antibiotic use and increased AIC utilization was observed after 2012, except for hospital B, which consistently used AICs.
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Affiliation(s)
- Stacey Podkovik
- Department of Neurological Surgery, Riverside University Health Sciences Medical Center, Riverside, California
| | - Chuan Zhou
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
- Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Susan E. Coffin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | | | | | - Matthew P. Kronman
- Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | | | - Ian F. Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sabrina Sedano
- Department of Hospital Medicine, Children’s Hospital Los Angeles, California
| | | | - Emily Thorell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Benjamin C. Warf
- Department of Neurosurgery, Harvard School of Medicine, Boston, Massachusetts; and
| | - Kathryn B. Whitlock
- Department of Hospital Medicine, Children’s Hospital Los Angeles, California
| | - Tamara D. Simon
- Department of Hospital Medicine, Children’s Hospital Los Angeles, California
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California
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Sedano S, Kronman MP, Whitlock KB, Zhou C, Coffin SE, Hauptman JS, Heller E, Mangano FT, Pollack IF, Schaffzin JK, Thorell E, Warf BC, Simon TD. Associations of Standard Care, Intrathecal Antibiotics, and Antibiotic-Impregnated Catheters With Cerebrospinal Fluid Shunt Infection Organisms and Resistance. J Pediatric Infect Dis Soc 2023; 12:504-512. [PMID: 37681670 PMCID: PMC10848219 DOI: 10.1093/jpids/piad064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/07/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Infection prevention techniques used during cerebrospinal fluid (CSF) shunt surgery include: (1) standard perioperative intravenous antibiotics, (2) intrathecal (IT) antibiotics, (3) antibiotic-impregnated catheter (AIC) shunt tubing, or (4) Both IT and AIC. These techniques have not been assessed against one another for their impact on the infecting organisms and patterns of antimicrobial resistance. METHODS We performed a retrospective longitudinal observational cohort study of children with initial CSF shunt placement between January 2007 and December 2012 at 6 US hospitals. Data were collected electronically from the Pediatric Health Information Systems+ (PHIS+) database, and augmented with standardized chart review. Only subjects with positive CSF cultures were included in this study. RESULTS Of 1,723 children whose initial shunt placement occurred during the study period, 196 (11%) developed infection, with 157 (80%) having positive CSF cultures. Of these 157 subjects, 69 (44%) received standard care, 28 (18%) received AIC, 55 (35%) received IT antibiotics, and 5 (3%) received Both at the preceding surgery. The most common organisms involved in monomicrobial infections were Staphylococcus aureus (38, 24%), coagulase-negative staphylococci (36, 23%), and Cutibacterium acnes (6, 4%). Compared with standard care, the other infection prevention techniques were not significantly associated with changes to infecting organisms; AIC was associated with decreased odds of methicillin resistance among coagulase-negative staphylococci. CONCLUSIONS Because no association was found between infection prevention technique and infecting organisms when compared to standard care, other considerations such as tolerability, availability, and cost should inform decisions about infection prevention during CSF shunt placement surgery.
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Affiliation(s)
- Sabrina Sedano
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Matthew P Kronman
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Chuan Zhou
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Susan E Coffin
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jason S Hauptman
- Center for Child Health, Behavior and Development, Seattle Children’s Research Institute, Seattle, Washington, USA
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Evan Heller
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Francesco T Mangano
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Ian F Pollack
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joshua K Schaffzin
- Department of Pediatrics, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | - Emily Thorell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Benjamin C Warf
- Department of Neurosurgery, Harvard School of Medicine, Boston, Massachusetts, USA
| | - Tamara D Simon
- Department of Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
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Simon TD, Sedano S, Rosenberg-Hasson Y, Durazo-Arvizu R, Whitlock KB, Hodor P, Hauptman JS, Limbrick DD, McDonald P, Ojemann JG, Maecker HT. Lower levels of Th1 and Th2 cytokines in cerebrospinal fluid (CSF) at the time of initial CSF shunt placement in children are associated with subsequent shunt revision surgeries. Cytokine 2023; 169:156310. [PMID: 37523803 PMCID: PMC10528342 DOI: 10.1016/j.cyto.2023.156310] [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: 05/25/2023] [Revised: 07/17/2023] [Accepted: 07/25/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE We compare cytokine profiles at the time of initial CSF shunt placement between children who required no subsequent shunt revision surgeries and children requiring repeated CSF shunt revision surgeries for CSF shunt failure. We also describe the cytokine profiles across surgical episodes for children who undergo multiple subsequent revision surgeries. METHODS This pilot study was nested within an ongoing prospective multicenter study collecting CSF samples and clinical data at the time of CSF shunt surgeries since August 2014. We selected cases where CSF was available for children who underwent an initial CSF shunt placement and had no subsequent shunt revision surgeries during >=24 months of follow-up (n = 7); as well as children who underwent an initial CSF shunt placement and then required repeated CSF shunt revision surgeries (n = 3). Levels of 92 human cytokines were measured using the Olink immunoassay and 41 human cytokines were measured using Luminex based bead array on CSF obtained at the time of each child's initial CSF shunt placement and were displayed in heat maps. RESULTS Qualitatively similar profiles for the majority of cytokines were observed among the patients in each group in both Olink and Luminex assays. Lower levels of MCP-3, CASP-8, CD5, CXCL9, CXCL11, eotaxin, IFN-γ, IL-13, IP-10, and OSM at the time of initial surgery were noted in the children who went on to require multiple surgeries. Pro- and anti-inflammatory cytokines were selected a priori and shown across subsequent revision surgeries for the 3 patients. Cytokine patterns differed between patients, but within a given patient pro-inflammatory and anti-inflammatory cytokines acted in a parallel fashion, with the exception of IL-4. CONCLUSIONS Heat maps of cytokine levels at the time of initial CSF shunt placement for each child undergoing only a single initial CSF shunt placement and for each child undergoing repeat CSF shunt revision surgeries demonstrated qualitatively similar profiles for the majority of cytokines. Lower levels of MCP-3, CASP-8, CD5, CXCL9, CXCL11, eotaxin, IFN-γ, IL-13, IP-10, and OSM at the time of initial surgery were noted in the children who went on to require multiple surgeries. Better stratification by patient age, etiology, and mechanism of failure is needed to develop a deeper understanding of the mechanism of inflammation in the development of hydrocephalus and response to shunting in children.
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Affiliation(s)
- Tamara D Simon
- Children's Hospital Los Angeles, Los Angeles, CA, United States; Department of Pediatrics, University of Southern California, Los Angeles, CA, United States; The Saban Research Institute, Los Angeles, CA, United States.
| | - Sabrina Sedano
- Children's Hospital Los Angeles, Los Angeles, CA, United States; Currently University of California San Francisco School of Medicine, San Francisco, CA, United States
| | - Yael Rosenberg-Hasson
- Human Immune Monitoring Center, Stanford School of Medicine, Palo Alto, CA, United States
| | - Ramon Durazo-Arvizu
- Children's Hospital Los Angeles, Los Angeles, CA, United States; The Saban Research Institute, Los Angeles, CA, United States
| | | | | | - Jason S Hauptman
- Seattle Children's Research Institute, Seattle, WA, United States; Department of Neurosurgery, University of Washington, Seattle, WA, United States
| | - David D Limbrick
- St. Louis Children's Hospital, St. Louis, MO, United States; Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, United States
| | - Patrick McDonald
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada; British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Jeffrey G Ojemann
- Seattle Children's Research Institute, Seattle, WA, United States; Department of Neurosurgery, University of Washington, Seattle, WA, United States
| | - Holden T Maecker
- Human Immune Monitoring Center, Stanford School of Medicine, Palo Alto, CA, United States
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Pandey S, Whitlock KB, Test MR, Hodor P, Pope CE, Limbrick DD, McDonald PJ, Hauptman JS, Hoffman LR, Simon TD. Characterization of cerebrospinal fluid (CSF) microbiota at the time of initial surgical intervention for children with hydrocephalus. PLoS One 2023; 18:e0280682. [PMID: 37342995 PMCID: PMC10284395 DOI: 10.1371/journal.pone.0280682] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/05/2023] [Indexed: 06/23/2023] Open
Abstract
OBJECTIVE To characterize the microbiota of the cerebrospinal fluid (CSF) from children with hydrocephalus at the time of initial surgical intervention. STUDY DESIGN CSF was obtained at initial surgical intervention. One aliquot was stored in skim milk-tryptone-glucose-glycerol (STGG) medium and the second was unprocessed; both were then stored at -70°C. Bacterial growth for CSF samples stored in STGG were subsequently characterized using aerobic and anaerobic culture on blood agar and MALDI-TOF sequencing. All unprocessed CSF samples underwent 16S quantitative polymerase chain reaction (qPCR) sequencing, and a subset underwent standard clinical microbiological culture. CSF with culture growth (either after storage in STGG or standard clinical) were further analyzed using whole-genome amplification sequencing (WGAS). RESULTS 11/66 (17%) samples stored in STGG and 1/36 (3%) that underwent standard clinical microbiological culture demonstrated bacterial growth. Of the organisms present, 8 were common skin flora and 4 were potential pathogens; only 1 was also qPCR positive. WGAS findings and STGG culture findings were concordant for only 1 sample, identifying Staphylococcus epidermidis. No significant difference in time to second surgical intervention was observed between the STGG culture-positive and negative groups. CONCLUSION(S) Using high sensitivity methods, we detected the presence of bacteria in a subset of CSF samples at the time of first surgery. Therefore, the true presence of bacteria in CSF of children with hydrocephalus cannot be ruled out, though our findings may suggest these bacteria are contaminants or false positives of the detection methods. Regardless of origin, the detection of microbiota in the CSF of these children may not have any clinical significance.
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Affiliation(s)
- Shailly Pandey
- University of Washington School of Medicine, Seattle, Washington, United States of America
| | - Kathryn B. Whitlock
- New Harmony Statistical Consulting, Clinton, Washington, United States of America
| | - Matthew R. Test
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Paul Hodor
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Christopher E. Pope
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - David D. Limbrick
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
- St. Louis Children’s Hospital, St. Louis, Missouri, United States of America
| | - Patrick J. McDonald
- Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Winnipeg Children’s Hospital, Winnipeg, Manitoba, Canada
| | - Jason S. Hauptman
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Neurosurgery, University of Washington, Seattle, Washington, United States of America
- Seattle Children’s Hospital, Seattle, Washington, United States of America
| | - Lucas R. Hoffman
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Seattle Children’s Hospital, Seattle, Washington, United States of America
| | - Tamara D. Simon
- Department of Pediatrics, University of Southern California, Los Angeles, California, United States of America
- The Saban Research Institute, Los Angeles, California, United States of America
- Children’s Hospital Los Angeles, Los Angeles, California, United States of America
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Pope CE, Whitlock KB, Hodor P, Limbrick DD, McDonald PJ, Hauptman J, Hoffman LR, Simon TD. A Refined, Controlled 16S rRNA Gene Sequencing Approach Reveals Limited Detection of Cerebrospinal Fluid Microbiota in Children with Bacterial Meningitis. Microbiol Spectr 2023; 11:e0036123. [PMID: 37140368 PMCID: PMC10269467 DOI: 10.1128/spectrum.00361-23] [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: 01/25/2023] [Accepted: 04/12/2023] [Indexed: 05/05/2023] Open
Abstract
Advances in both laboratory and computational components of high-throughput 16S amplicon sequencing (16S HTS) have markedly increased its sensitivity and specificity. Additionally, these refinements have better delineated the limits of sensitivity, and contributions of contamination to these limits, for 16S HTS that are particularly relevant for samples with low bacterial loads, such as human cerebrospinal fluid (CSF). The objectives of this work were to (i) optimize the performance of 16S HTS in CSF samples with low bacterial loads by defining and addressing potential sources of error, and (ii) perform refined 16S HTS on CSF samples from children diagnosed with bacterial meningitis and compare results with those from microbiological cultures. Several bench and computational approaches were taken to address potential sources of error for low bacterial load samples. We compared DNA yields and sequencing results after applying three different DNA extraction approaches to an artificially constructed mock-bacterial community. We also compared two postsequencing computational contaminant removal strategies, decontam R and full contaminant sequence removal. All three extraction techniques followed by decontam R yielded similar results for the mock community. We then applied these methods to 22 CSF samples from children diagnosed with meningitis, which has low bacterial loads relative to other clinical infection samples. The refined 16S HTS pipelines identified the cultured bacterial genus as the dominant organism for only 3 of these samples. We found that all three DNA extraction techniques followed by decontam R generated similar DNA yields for mock communities at the low bacterial loads representative of CSF samples. However, the limits of detection imposed by reagent contaminants and methodologic bias precluded the accurate detection of bacteria in CSF from children with culture-confirmed meningitis using these approaches, despite rigorous controls and sophisticated computational approaches. Although we did not find current DNA-based diagnostics to be useful for pediatric meningitis samples, the utility of these methods for CSF shunt infection remains undefined. Future advances in sample processing methods to minimize or eliminate contamination will be required to improve the sensitivity and specificity of these methods for pediatric meningitis. IMPORTANCE Advances in both laboratory and computational components of high-throughput 16S amplicon sequencing (16S HTS) have markedly increased its sensitivity and specificity. These refinements have better delineated the limits of sensitivity, and contributions of contamination to these limits, for 16S HTS that are particularly relevant for samples with low bacterial loads such as human cerebrospinal fluid (CSF). The objectives of this work were to (i) optimize the performance of 16S HTS in CSF samples by defining and addressing potential sources of error, and (ii) perform refined 16S HTS on CSF samples from children diagnosed with bacterial meningitis and compare results with those from microbiological cultures. We found that the limits of detection imposed by reagent contaminants and methodologic bias precluded the accurate detection of bacteria in CSF from children with culture-confirmed meningitis using these approaches, despite rigorous controls and sophisticated computational approaches.
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Affiliation(s)
- Christopher E. Pope
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
| | | | - Paul Hodor
- Seattle Children's Research Institute, Seattle, Washington, USA
| | - David D. Limbrick
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, USA
- St. Louis Children’s Hospital, St. Louis, Missouri, USA
| | - Patrick J. McDonald
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Jason Hauptman
- Seattle Children's Research Institute, Seattle, Washington, USA
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Lucas R. Hoffman
- Department of Pediatrics, University of Washington, Seattle, Washington, USA
- Seattle Children's Research Institute, Seattle, Washington, USA
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Tamara D. Simon
- Department of Pediatrics, University of Southern California, Los Angeles, California, USA
- The Saban Research Institute, Los Angeles, California, USA
- Children’s Hospital Los Angeles, Los Angeles, California, USA
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Bonilla-Velez J, Whitlock KB, Ganti S, Shivaram GM, Bly RA, Dahl JP, Manning SC, Perkins JA. Delaying Invasive Treatment in Unilateral Head and Neck Lymphatic Malformation Improves Outcomes. Laryngoscope 2023; 133:956-962. [PMID: 35657104 DOI: 10.1002/lary.30237] [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] [Received: 02/09/2022] [Revised: 04/21/2022] [Accepted: 05/19/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Large (De Serres stage [IV-V]) head and neck lymphatic malformations (HNLMs) often have multiple, high-risk, invasive treatments (ITs) to address functional compromise. Logically reducing HNLM ITs should reduce treatment risk. We tested whether delaying HNLM ITs reduces total IT number. MATERIALS Consecutive HNLM patients (n = 199) between 2010 and 2017, aged 0-18 years. METHODS ITs (surgery or sclerotherapy) were offered for persistent or dysfunction causing HNLMs. Treatment effectiveness categorized by IT number: optimal (0-1), acceptable (2-5), or suboptimal (>5). Clinical data were summarized, and outcome associations tested (χ2 ). Relative risk (RR) with a Poisson working model tested whether HNLM observation or IT delay (>6 months post-diagnosis) predicts treatment success (i.e., ≤1 IT). RESULTS Median age at HNLM diagnosis was 1.3 months (interquartile range [IQR] 0-45 m) with 107/199(54%) male. HNLM were stage I-III (174 [88%]), IV-V (25 [13%]). Initial treatment was observation (70 [35%]), invasive (129 [65%]). Treatment outcomes were optimal (137 [69%]), acceptable (36 [18%]), and suboptimal (26 [13%]). Suboptimal outcome associations: EXIT procedure, stage IV-V, oral location, and tracheotomy (p < 0.001). Stage I-III HNLMs were initially observed compared with stage I-III having ITs within 6 months of HNLM diagnosis, had a 82% lower relative treatment failure risk ([i.e., >1 IT], RR = 0.09, 95% CI 0.02-0.36, p < 0.001). Stage I-III HNLMs with non-delayed ITs had reduced treatment failure risk compared with IV-V (RR = 0.47, 95% CI 0.33-0.66, p < 0.001). CONCLUSION Observation and delayed IT in stage I-III HNLM ("Grade 1") is safe and reduces IT (i.e., ≤1 IT). Stage IV-V HNLMs ("Grade 2") with early IT have a greater risk of multiple ITs. LEVEL OF EVIDENCE 4 Laryngoscope, 133:956-962, 2023.
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Affiliation(s)
- Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Kathryn B Whitlock
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Sheila Ganti
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Giri M Shivaram
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A.,Interventional Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Randall A Bly
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - John P Dahl
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Scott C Manning
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
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8
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Bonilla-Velez J, Whitlock KB, Ganti S, Zenner K, Cheng CV, Jensen DM, Pham MHM, Mitchell RM, Dobyns W, Bly RA, Bennett JT, Dahl JP, Perkins JA. Acetylsalicylic acid suppression of the PI3K pathway as a novel medical therapy for head and neck lymphatic malformations. Int J Pediatr Otorhinolaryngol 2021; 151:110869. [PMID: 34537546 PMCID: PMC9632366 DOI: 10.1016/j.ijporl.2021.110869] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 07/21/2021] [Accepted: 08/04/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Head and neck lymphatic malformations (HNLM) are caused by gain-of-function somatic mutations in PIK3CA. Acetylsalicylic acid (ASA/aspirin) is thought to limit growth in PIK3CA-mutated neoplasms through PI3K pathway suppression. We sought to determine if ASA could be beneficial for HNLM. METHODS Retrospective case series of patients (0-18 years) offered ASA (3-5 mg/kg/day) for HNLM treatment (2010-2018). Clinical and treatment characteristics, patient-reported symptom improvement, medication tolerance, compliance, and complications were recorded. Treatment response was determined by change in patient/caregiver-reported symptoms, or HNLM size [complete (resolved), partial (decreased), or stable]. RESULTS Fifty-three patients were offered ASA, 23 (43%) accepted (median age 10 years, IQR 6-14). Compared to patients who declined, patients receiving ASA were more likely to have extensive malformations: ex-utero intrapartum treatment procedure, bilateral malformations, oral cavity location, ≥2 invasive treatments, or tracheotomy (p < 0.05). All patients with tissue available had PIK3CA mutations (13/23). Treatment indications included oral pain/blebs (12, 52%), recurrent pain/swelling (6, 26%), or sudden/persistent swelling (5, 22%). Treatment plan was commonly one 81 mg tablet daily (19, 83%) for 3-12 months (8, 42%). Therapeutic adherence was reported by 18 patients (78%). Symptoms improved in 18 patients [78%; decreased pain (9, 39%) and swelling (8, 35%)]. Treatment resulted in partial (14, 61%) or complete response (4, 17%). Three patients developed oral bleb bleeding, which resolved with medication discontinuation. CONCLUSION ASA seems to be a well-tolerated, low-risk medication for HNLM treatment. This pilot study suggests that it often improves symptoms and reduces HNLM size. Further prospective, randomized studies are warranted to comprehensively assess indications, safety, and efficacy. LEVEL OF EVIDENCE Level 4.
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Affiliation(s)
- Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, WA, USA; Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA.
| | - Kathryn B. Whitlock
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Sheila Ganti
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Kaitlyn Zenner
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Chi Vicky Cheng
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Dana M. Jensen
- Center for Developmental Biology and Regenerative Medicine, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Minh-Hang M. Pham
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Ryan M. Mitchell
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, Indiana University, Indianapolis, IN, USA
| | - William Dobyns
- Center for Integrative Brain Research, Seattle Children’s Research Institute, Seattle, WA, USA
| | - Randall A. Bly
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - James T. Bennett
- Center for Developmental Biology and Regenerative Medicine, Seattle Children’s Research Institute, Seattle, WA, USA,Division of Genetic Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA, USA
| | - John P. Dahl
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Jonathan A. Perkins
- Division of Pediatric Otolaryngology, Seattle Children’s Hospital, Seattle, WA, USA,Department of Otolaryngology–Head and Neck Surgery, University of Washington School of Medicine, Seattle, WA, USA,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA, USA
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9
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Hodor P, Pope CE, Whitlock KB, Hoffman LR, Limbrick DL, McDonald PJ, Hauptman JS, Ojemann JG, Simon TD. Molecular Characterization of Microbiota in Cerebrospinal Fluid From Patients With CSF Shunt Infections Using Whole Genome Amplification Followed by Shotgun Sequencing. Front Cell Infect Microbiol 2021; 11:699506. [PMID: 34490140 PMCID: PMC8417900 DOI: 10.3389/fcimb.2021.699506] [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: 05/03/2021] [Accepted: 07/29/2021] [Indexed: 11/13/2022] Open
Abstract
Understanding the etiology of cerebrospinal fluid (CSF) shunt infections and reinfections requires detailed characterization of associated microorganisms. Traditionally, identification of bacteria present in the CSF has relied on culture methods, but recent studies have used high throughput sequencing of 16S rRNA genes. Here we evaluated the method of shotgun DNA sequencing for its potential to provide additional genomic information. CSF samples were collected from 3 patients near the beginning and end of each of 2 infection episodes. Extracted total DNA was sequenced by: (1) whole genome amplification followed by shotgun sequencing (WGA) and (2) high-throughput sequencing of the 16S rRNA V4 region (16S). Taxonomic assignments of sequences from WGA and 16S were compared with one another and with conventional microbiological cultures. While classification of bacteria was consistent among the 3 approaches, WGA provided additional insights into sample microbiological composition, such as showing relative abundances of microbial versus human DNA, identifying samples of questionable quality, and detecting significant viral load in some samples. One sample yielded sufficient non-human reads to allow assembly of a high-quality Staphylococcus epidermidis genome, denoted CLIMB1, which we characterized in terms of its MLST profile, gene complement (including putative antimicrobial resistance genes), and similarity to other annotated S. epidermidis genomes. Our results demonstrate that WGA directly applied to CSF is a valuable tool for the identification and genomic characterization of dominant microorganisms in CSF shunt infections, which can facilitate molecular approaches for the development of better diagnostic and treatment methods.
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Affiliation(s)
- Paul Hodor
- Seattle Children's Hospital, Seattle, WA, United States
| | - Christopher E Pope
- Department of Pediatrics, University of Washington, Seattle, WA, United States
| | | | - Lucas R Hoffman
- Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - David L Limbrick
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, MO, United States
| | - Patrick J McDonald
- Division of Neurosurgery, University of British Columbia, Vancouver, BC, Canada
| | - Jason S Hauptman
- Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Jeffrey G Ojemann
- Seattle Children's Hospital, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Tamara D Simon
- Children's Hospital Los Angeles, Los Angeles, CA, United States.,Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, CA, United States
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10
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Wandell GM, Wang X, Whitlock KB, Weber AK, Sie KCY, Bonilla-Velez J. Are Spanish-Speaking Families Less Satisfied with Care in Pediatric Otolaryngology? Laryngoscope 2021; 131:E2393-E2401. [PMID: 33586795 DOI: 10.1002/lary.29387] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/10/2020] [Accepted: 12/26/2020] [Indexed: 11/10/2022]
Abstract
OBJECTIVES/HYPOTHESIS Language barriers may impact family experience, which is a key measure of healthcare quality. We compared family satisfaction between Spanish-speaking families (SSF) and English-speaking families (ESF) in pediatric otolaryngology. STUDY DESIGN Retrospective cohort study. METHODS Responses from the Family Experience Survey (FES), a hospital quality benchmarking survey, were analyzed from 2017 to 2019 at one academic pediatric otolaryngology practice. Question responses were compared between SSF versus ESF using mixed effect logistic regression models, adjusting for patient age, medical complexity, and insurance. RESULTS A total of 4,964 FES survey responses were included (14% SSF). In multivariate analysis adjusting for age, medical complexity, and insurance, SSF were 1.7 times more likely than ESF to rate their provider with the highest rating (i.e. 9-10/10; 95% confidence interval [CI] 1.24-2.22). However, SSF were less likely than ESF to provide the highest rating on many individual aspects of care, including whether providers explained things intelligibly (odds ratio [OR] 0.43, 95% CI 0.25-0.74), listened carefully (OR 0.36, 95% CI 0.28-0.47), knew their medical child's history (OR 0.53, 95% CI 0.44-0.64), provided understandable information (OR 0.36, 95% CI 0.16-0.83), spent sufficient time with them (OR 0.38, 95% CI 0.31-0.48), allowed them to discuss their questions (OR 0.57, 95% CI 0.47-0.70), or had enough input in their children's' care (OR 0.46, 95% CI 0.26-0.80). CONCLUSIONS In a large cohort of pediatric otolaryngology patients, SSF rated many individual aspects of their child's care less positively compared to ESF, despite rating their provider highly. Further research is needed to explore the reasons for these differences and how they can be improved. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2393-E2401, 2021.
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Affiliation(s)
- Grace M Wandell
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Xing Wang
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Kathryn B Whitlock
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Alizabeth K Weber
- Department of Otolaryngology-Head and Neck Surgery, Saint Louis University, Saint Louis, Missouri, USA
| | - Kathleen C Y Sie
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Juliana Bonilla-Velez
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA.,Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, USA.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
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11
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Roth CL, Perez FA, Whitlock KB, Elfers C, Yanovski JA, Shoemaker AH, Abuzzahab MJ. A phase 3 randomized clinical trial using a once-weekly glucagon-like peptide-1 receptor agonist in adolescents and young adults with hypothalamic obesity. Diabetes Obes Metab 2021; 23:363-373. [PMID: 33026160 PMCID: PMC7821019 DOI: 10.1111/dom.14224] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/24/2020] [Accepted: 10/04/2020] [Indexed: 12/13/2022]
Abstract
AIM To evaluate the efficacy, safety and tolerability of a glucagon-like peptide-1 receptor agonist (GLP-1 RA) in patients with hypothalamic obesity (HO). MATERIALS AND METHODS A two-arm, randomized, multicentre, double-blind, placebo-controlled trial was conducted in 10- to 25-year-olds with hypothalamic injury following intracranial tumour and HO. Participants were randomized to once-weekly subcutaneous injections of a GLP-1 RA exenatide 2 mg (ExQW) or placebo for 36 weeks. The primary efficacy endpoint was 36-week % change in body mass index (BMI). Secondary outcomes included change in body composition (by dual energy x-ray absorptiometry). RESULTS Forty-two participants were randomized to ExQW (n = 23) or placebo (n = 19). Participants were 5 ± 2 years (mean ± SD) postdiagnosis and development of HO (BMI 37.3 ± 7.1 kg/m2 ). In intention-to-treat analysis, the effect of 36-week ExQW vs. placebo on % Δ BMI was not significant (estimated treatment difference -1.7 ± 1.8%, 95% CI -4.1 to 0.6%, P = .40); however, total body fat mass was reduced (estimated treatment difference -3.1 ± 1.4 kg, 95% CI -5.7 to -0.4 kg, P = .02). There was a significant reduction in waist circumference (estimated effect of treatment -3.5 [95% CI -5.5 to -1.6] cm, P = .004). All patients treated with placebo increased % of adipose tissue, while 50% treated with ExQW had reductions (P < .001). Mean HbA1c, glucose tolerance and serum lipids did not change significantly with therapy. ExQW was well tolerated. The most frequent adverse events were transient gastrointestinal disturbances (ExQW vs. placebo: nausea 6/23 vs. 3/18, vomiting 4/23 vs. 4/18 and diarrhoea 7/23 vs. 3/18). CONCLUSIONS GLP-1 RAs are a promising and safe treatment to improve or stabilize HO in children and young adults.
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Affiliation(s)
- Christian L. Roth
- Seattle Children's Research InstituteSeattleWashington
- Department of PediatricsUniversity of WashingtonSeattleWashington
| | - Francisco A. Perez
- Department of RadiologySeattle Children's and University of WashingtonSeattleWashington
| | | | | | - Jack A. Yanovski
- Section on Growth and Obesity, Division of Intramural ResearchEunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of HealthBethesdaMaryland
| | - Ashley H. Shoemaker
- Division of Pediatric EndocrinologyVanderbilt University Medical CenterNashvilleTennessee
| | - M. Jennifer Abuzzahab
- McNeely Pediatric Diabetes Center and Endocrinology ClinicChildren's MinnesotaSt. PaulMinnesota
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12
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Whitlock KB, Pope CE, Hodor P, Hoffman LR, Limbrick DL, McDonald PJ, Hauptman JS, Ojemann JG, Simon TD. Characterization of cerebrospinal fluid (CSF) microbiota from patients with CSF shunt infection and reinfection using high throughput sequencing of 16S ribosomal RNAgenes. PLoS One 2021; 16:e0244643. [PMID: 33406142 PMCID: PMC7787469 DOI: 10.1371/journal.pone.0244643] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 12/15/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Nearly 20% of patients with cerebrospinal fluid (CSF) shunt infection develop reinfection. It is unclear whether reinfections are caused by an organism previously present or are independent infection events. OBJECTIVE We used bacterial culture and high throughput sequencing (HTS) of 16S ribosomal RNA (rRNA) genes to identify bacteria present in serial CSF samples obtained from children who failed CSF shunt infection treatment. We hypothesized that organisms that persist in CSF despite treatment would be detected upon reinfection. DESIGN/METHODS Serial CSF samples were obtained from 6 patients, 5 with 2 infections and 1 with 3 infections; the study was limited to those for which CSF samples were available from the end of infection and beginning of reinfection. Amplicons of the 16S rRNA gene V4 region were sequenced. Taxonomic assignments of V4 sequences were compared with bacterial species identified in culture. RESULTS Seven infection dyads averaging 13.5 samples per infection were analyzed. A median of 8 taxa [interquartile range (IQR) 5-10] were observed in the first samples from reinfection using HTS. Conventional culture correlated with high abundance of an organism by HTS in all but 1 infection. In 6 of 7 infection dyads, organisms identified by culture at reinfection were detected by HTS of culture-negative samples at the end of the previous infection. The median Chao-Jaccard abundance-based similarity index for matched infection pairs at end of infection and beginning of reinfection was 0.57 (IQR 0.07-0.87) compared to that for unmatched pairs of 0.40 (IQR 0.10-0.60) [p = 0.46]. CONCLUSION(S) HTS results were generally consistent with culture-based methods in CSF shunt infection and reinfection, and may detect organisms missed by culture at the end of infection treatment but detected by culture at reinfection. However, the CSF microbiota did not correlate more closely within patients at the end of infection and beginning of reinfection than between any two unrelated infections. We cannot reject the hypothesis that sequential infections were independent.
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Affiliation(s)
- Kathryn B. Whitlock
- New Harmony Statistical Consulting LLC, Shoreline, Washington, United States of America
| | - Christopher E. Pope
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Paul Hodor
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - Lucas R. Hoffman
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
| | - David L. Limbrick
- Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri, United States of America
- St. Louis Children’s Hospital, St. Louis, Missouri, United States of America
| | - Patrick J. McDonald
- Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
- British Columbia Children’s Hospital, Vancouver, British Columbia, Canada
| | - Jason S. Hauptman
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Neurosurgery, University of Washington, Seattle, Washington, United States of America
| | - Jeffrey G. Ojemann
- Seattle Children’s Research Institute, Seattle, Washington, United States of America
- Department of Neurosurgery, University of Washington, Seattle, Washington, United States of America
| | - Tamara D. Simon
- Department of Pediatrics, Keck School of Medicine at the University of Southern California, Los Angeles, California, United States of America
- Children’s Hospital Los Angeles and The Saban Research Institute, Los Angeles, California, United States of America
- * E-mail:
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13
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Bonilla-Velez J, Whitlock KB, Ganti S, Theeuwen HA, Manning SC, Bly RA, Dahl JP, Perkins JA. Active Observation as an Alternative to Invasive Treatments for Pediatric Head and Neck Lymphatic Malformations. Laryngoscope 2020; 131:1392-1397. [PMID: 33107991 DOI: 10.1002/lary.29180] [Citation(s) in RCA: 2] [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] [Received: 05/29/2020] [Revised: 09/02/2020] [Accepted: 09/21/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVES An increasing number of treatment modalities for lymphatic malformations are being described, complicating therapeutic decisions. Understanding lymphatic malformation natural history is essential. We describe management of head and neck lymphatic malformations where decisions primarily addressed lesion-induced functional compromise (ie, breathing, swallowing) to identify factors associated with invasive treatment and active observation. We hypothesize that non-function threatening malformations can be observed. STUDY DESIGN Retrospective case series. METHODS Retrospective case series of consecutive head and neck lymphatic malformation patients (2000-2017) with over 2 years of follow-up. Patient characteristics were summarized and associations with invasive treatment (surgery or sclerotherapy) tested using Fisher's exact. In observed patients, factors associated with spontaneous regression were assessed with Fisher's exact test. RESULTS Of 191 patients, 101 (53%) were male, 97 (51%) Caucasian, and 98 (51.3%) younger than 3 months. Malformations were de Serres I-III 167 (87%), or IV-V 24 (12%), and commonly located in the neck (101, 53%), or oral cavity (36, 19%). Initial treatments included observation (65, 34%) or invasive treatments such as primary surgery (80, 42%), staged surgery (25, 13%), or primary sclerotherapy (9, 5%). Of 65 initially observed malformations, 8 (12%) subsequently had invasive treatment, 36 (58%) had spontaneous regression, and 21 (32%) elected for no invasive therapy. Spontaneous regression was associated with location in the lateral neck (P = .003) and macrocystic malformations (P = .017). CONCLUSION Head and neck lymphatic malformation treatment selection can be individualized after stratifying by stage, presence of functional compromise, and consideration of natural history. Recognizing the spectrum of severity is essential in evaluating efficacy of emerging treatments, as selected malformations may respond to observation. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1392-1397, 2021.
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Affiliation(s)
- Juliana Bonilla-Velez
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Kathryn B Whitlock
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Sheila Ganti
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Hailey A Theeuwen
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Scott C Manning
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
| | - Randall A Bly
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - John P Dahl
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington School of Medicine, Seattle, Washington, U.S.A.,Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, U.S.A
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14
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Meert KL, Reeder R, Maddux AB, Banks R, Berg RA, Zuppa A, Newth CJ, Wessel D, Pollack MM, Hall MW, Quasney M, Sapru A, Carcillo JA, McQuillen PS, Mourani PM, Chima RS, Holubkov R, Sorenson S, Varni JW, McGalliard J, Haaland W, Whitlock KB, Dean JM, Zimmerman JJ. Trajectories and Risk Factors for Altered Physical and Psychosocial Health-Related Quality of Life After Pediatric Community-Acquired Septic Shock. Pediatr Crit Care Med 2020; 21:869-878. [PMID: 32667767 PMCID: PMC9059316 DOI: 10.1097/pcc.0000000000002374] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the physical and psychosocial domains of health-related quality of life among children during the first year following community-acquired septic shock, and explore factors associated with poor physical and psychosocial health-related quality of life outcomes. DESIGN Secondary analysis of the Life After Pediatric Sepsis Evaluation. SETTING Twelve academic PICUs in the United States. PATIENTS Children greater than or equal to 1 month and less than 18 years old who were perceived to be without severe developmental disability by their family caregiver at baseline and who survived hospitalization for community-acquired septic shock. INTERVENTIONS Family caregivers completed the Pediatric Quality of Life Inventory for children 2-18 years old or the Pediatric Quality of Life Inventory Infant Scales for children less than 2 years old at baseline (reflecting preadmission status), day 7, and months 1, 3, 6, and 12 following PICU admission. Higher Pediatric Quality of Life Inventory Physical and Psychosocial Health Summary Scores indicate better health-related quality of life. MEASUREMENTS AND MAIN RESULTS Of 204 children, 58 (28.2%) had a complex chronic comorbid condition. Children with complex chronic comorbid conditions had lower baseline physical health-related quality of life (62.7 ± 22.6 vs 84.1 ± 19.7; p < 0.001) and psychosocial health-related quality of life (68.4 ± 14.1 vs 81.2 ± 15.3; p < 0.001) than reference norms, whereas children without such conditions had baseline scores similar to reference norms. Children with complex chronic comorbid conditions recovered to their baseline health-related quality of life, whereas children without such conditions did not (physical health-related quality of life 75.3 ± 23.7 vs 83.2 ± 20.1; p = 0.008 and psychosocial health-related quality of life 74.5 ± 18.7 vs 80.5 ± 17.9; p = 0.006). Age less than 2 years was independently associated with higher month 12 physical health-related quality of life, and abnormal neurologic examination and neurologic injury suspected by a healthcare provider during the PICU course were independently associated with lower month 12 physical health-related quality of life. Treatment of increased intracranial pressure and medical device use at month 1 were independently associated with lower month 12 psychosocial health-related quality of life. CONCLUSIONS Physical and psychosocial health-related quality of life were reduced among children during the first year following community-acquired septic shock compared with reference norms, although many recovered to baseline. Risk factors for poor health-related quality of life included neurologic complications during the hospitalization and dependence on a medical device 1 month postadmission.
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Affiliation(s)
- Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University, Detroit, MI
| | - Ron 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
| | - Athena Zuppa
- 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
| | - David Wessel
- Department of Pediatrics, Children’s National Hospital, Washington DC
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National Hospital, Washington DC
| | - 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
| | - 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
| | - 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
| | - James W. Varni
- Department of Pediatrics, Texas A&M University, College Station, TX
| | - Julie McGalliard
- Center for Child Health, Behavior and Development, Seattle Children’s Hospital, Seattle Research Institute, Seattle, WA
| | - Wren Haaland
- Department of Pediatrics, Seattle Children’s Hospital, Seattle Research Institute, University of Washington School of Medicine, Seattle, WA
| | - Kathryn B. Whitlock
- Center for Clinical and Translational Research, 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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15
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Chronis-Tuscano A, French W, Strickland J, Sasser T, Gonzalez ENS, Whitlock KB, Stein MA. Acute Effects of Parent Stimulant Medication Versus Behavioral Parent Training on Mothers' ADHD, Parenting Behavior, and At-Risk Children. J Clin Psychiatry 2020; 81. [PMID: 32926603 DOI: 10.4088/jcp.19m13173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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] [Received: 11/29/2019] [Accepted: 07/21/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Attention-deficit/hyperactivity disorder (ADHD) is present in 25%-50% of parents of children with ADHD, compromising parenting and child behavioral treatment. Efforts to treat multiplex ADHD families have not compared behavioral parenting interventions to parent psychopharmacology without confounds of other treatments. This report describes a pilot early intervention study directly comparing parent lisdexamfetamine dimesylate (LDX) to behavioral parent training (BPT) in families in which the mother had currently untreated ADHD and the young child displayed ADHD symptoms. METHODS Mothers with ADHD (N = 35) of 4- to 8-year-old stimulant-naive children (N = 35) were randomly assigned to an 8-week trial of LDX (starting at 20 mg/d and titrated to a maximum of 70 mg/d) or BPT. Outcomes included multi-method, multi-informant measures of (1) maternal ADHD symptoms (Conners' Adult ADHD Rating Scales) and impairment (Clinical Global Impressions-Severity of Illness scale [CGI-S] and CGI-Improvement scale [CGI-I]), (2) parenting (Alabama Parenting Questionnaire [APQ] and Dyadic Parent-Child Interaction Coding System, Fourth Edition), and (3) child ADHD symptoms (Conners Parent Rating Scale Revised-Short Form and Conners Early Childhood Scale) and impairment (CGI-S, CGI-I, and Child Impairment Rating Scale). RESULTS At 8 weeks, both treatments improved mothers' self-reported emotion regulation and mothers' functioning on the CGI, but only LDX improved mothers' self-reported core ADHD symptoms. LDX was associated with improvement in parents' perception of their own ADHD symptoms (Conners Inattention [P < .0001] and ADHD Index scores [P < .0001]) and their child's ADHD symptoms (P = .009). Fifty-six percent of the mothers treated with LDX (n = 10) were "much" or "very much" improved with regard to their adult ADHD based on the CGI-I scores versus 6% of mothers receiving BPT (n = 1; P = .003). BPT improved parenting on self-reported positive parenting (P = .007), inconsistent discipline (P > .0001), and corporal punishment (P = .001), while LDX improved reported inconsistent discipline (P = .001) and corporal punishment (P = .04) on the APQ, consistent with prior research. In contrast to parental LDX, which did not improve observed parenting, BPT was associated with increased positive parenting during child-directed play (P = .0002) and clean-up (P = .04) and less negative parenting (P = .04) during child-directed play. Six percent of children (n = 1) whose mothers were randomized to LDX (n = 18) were "much" or "very much" improved on the CGI-I compared to 35% (n = 16) of those treated with BPT (P = .04). CONCLUSIONS LDX and BPT each had unique effects on maternal ADHD symptoms and parenting, but modest effects on at-risk children. In general, LDX was more effective at treating mothers' core ADHD symptoms, but both LDX and BPT improved mothers' emotion regulation, and BPT resulted in more consistent effects on parenting measures via both maternal report and direct observation. As most children remained significantly impaired after 8 weeks of unimodal treatment, combination treatment and/or longer treatment duration may be necessary to improve functioning of multiplex ADHD families. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01816074.
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Affiliation(s)
- Andrea Chronis-Tuscano
- Department of Psychology, University of Maryland College Park, College Park, Maryland, USA
| | - William French
- University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Tyler Sasser
- University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington, USA
| | - Erin N Schoenfelder Gonzalez
- University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Mark A Stein
- Department of Psychiatry and Behavioral Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105. .,University of Washington School of Medicine, Seattle, Washington, USA.,Seattle Children's Research Institute, Seattle, Washington, USA
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16
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Ong T, Liu CC, Elder L, Hill L, Abts M, Dahl JP, Evans KN, Parikh SR, Soares JJ, Striegl AM, Whitlock KB, Johnson KE. The Trach Safe Initiative: A Quality Improvement Initiative to Reduce Mortality among Pediatric Tracheostomy Patients. Otolaryngol Head Neck Surg 2020; 163:221-231. [PMID: 32204663 DOI: 10.1177/0194599820911728] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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: 12/30/2022]
Abstract
OBJECTIVE To describe the Trach Safe Initiative and assess its impact on unanticipated tracheostomy-related mortality in outpatient tracheostomy-dependent children (TDC). METHODS An interdisciplinary team including parents and providers designed the initiative with quality improvement methods. Three practice changes were prioritized: (1) surveillance airway endoscopy prior to hospital discharge from tracheostomy placement, (2) education for community-based nurses on TDC-focused emergency airway management, and (3) routine assessment of airway events for TDC in clinic. The primary outcome was annual unanticipated mortality after hospital discharge from tracheostomy placement before and after the initiative. RESULTS In the 5 years before and after the initiative, 131 children and 155 children underwent tracheostomy placement, respectively. At the end of the study period, the institution sustained Trach Safe practices: (1) surveillance bronchoscopies increased from 104 to 429 bronchoscopies, (2) the course trained 209 community-based nurses, and (3) the survey was used in 488 home ventilator clinic visits to identify near-miss airway events. Prior to the initiative, 9 deaths were unanticipated. After Trach Safe implementation, 1 death was unanticipated. Control chart analysis demonstrates significant special-cause variation in reduced unanticipated mortality. DISCUSSION We describe a system shift in reduced unanticipated mortality for TDC through 3 major practice changes of the Trach Safe Initiative. IMPLICATION FOR PRACTICE Death in a child with a tracheostomy tube at home may represent modifiable tracheostomy-related airway events. Using Trach Safe practices, we address multiple facets to improve safety of TDC out of the hospital.
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Affiliation(s)
- Thida Ong
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - C Carrie Liu
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Leslie Elder
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Leslee Hill
- Seattle Children's Hospital, Seattle, Washington, USA
| | - Matthew Abts
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - John P Dahl
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Kelly N Evans
- Seattle Children's Hospital, Seattle, Washington, USA.,Craniofacial Medicine, University of Washington, Seattle Children's Hospital, Seattle, Washington, USA
| | - Sanjay R Parikh
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | | | - Amanda M Striegl
- Pediatric Pulmonary and Sleep Medicine, University of Washington, Seattle, Washington, USA.,Seattle Children's Hospital, Seattle, Washington, USA
| | - Kathryn B Whitlock
- Center for Clinical and Translational Research, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kaalan E Johnson
- Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, Washington, USA.,Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, USA
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17
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Chrisman SPD, Whitlock KB, Mendoza JA, Burton MS, Somers E, Hsu A, Fay L, Palermo TM, Rivara FP. Corrigendum: Pilot Randomized Controlled Trial of an Exercise Program Requiring Minimal In-person Visits for Youth With Persistent Sport-Related Concussion. Front Neurol 2020; 11:6. [PMID: 32153484 PMCID: PMC7047157 DOI: 10.3389/fneur.2020.00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Accepted: 01/07/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sara P D Chrisman
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention and Research Center, Seattle, WA, United States
| | - Kathryn B Whitlock
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Jason A Mendoza
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Monique S Burton
- Department of Pediatrics, University of Washington, Seattle, WA, United States.,Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Ellie Somers
- Department of Sports Physical Therapy, Seattle Children's Hospital, Seattle, WA, United States
| | - Albert Hsu
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Lauren Fay
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Tonya M Palermo
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Frederick P Rivara
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention and Research Center, Seattle, WA, United States
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18
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Connell SK, Rutman LE, Whitlock KB, Haviland MJ, Simmons S, Schloredt K, Ramos J, Brewer K, Augustine M, Lion KC. Health Care Reform, Length of Stay, and Readmissions for Child Mental Health Hospitalizations. Hosp Pediatr 2020; 10:238-245. [PMID: 32014883 DOI: 10.1542/hpeds.2019-0197] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Health care reform may impact inpatient mental health services by increasing access and changing insurer incentives. We examined whether implementation of the 2014 Affordable Care Act (ACA) was associated with changes in psychiatric length of stay (LOS) and 30-day readmissions for pediatric patients. METHODS We conducted an interrupted time-series analysis to evaluate LOS and 30-day readmissions during the 30 months before and 24 months after ACA implementation, with a 6-month wash-out period, on patients aged 4 to 17 years who were discharged from the psychiatry unit of a children's hospital. Differences by payer (Medicaid versus non-Medicaid) were examined in moderated interrupted time series. Logistic regression was used to examine the association between psychiatric LOS and 30-day readmissions. RESULTS There were 1874 encounters in the pre-ACA period and 2186 encounters in the post-ACA period. Compared with pre-ACA implementation, post-ACA implementation was associated with LOS that was significantly decreasing over time (pre-ACA versus post-ACA slope difference: -0.10 days per encounter per month [95% confidence interval -0.17 to -0.02]; P = .01), especially for Medicaid-insured patients (pre-ACA versus post-ACA slope difference: -0.14 days per encounter per month [95% confidence interval -0.26 to -0.01]; P = .03). The overall proportion of 30-day readmissions increased significantly (pre-ACA 6%, post-ACA 10%; P < .05 for the difference). We found no association between LOS and 30-day readmissions. CONCLUSIONS ACA implementation was associated with a decline in psychiatric inpatient LOS over time, especially for those on Medicaid, and an increase in 30-day readmissions. LOS was not associated with 30-day inpatient readmissions. Further investigation to understand the drivers of these patterns is warranted.
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Affiliation(s)
- Sarah K Connell
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington;
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Lori E Rutman
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
- Pediatric Emergency Medicine and
| | - Kathryn B Whitlock
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Miriam J Haviland
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Shannon Simmons
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Kelly Schloredt
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Jessica Ramos
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Kathy Brewer
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Marie Augustine
- Psychiatry and Behavioral Medicine, Seattle Children's Hospital, Seattle, Washington
| | - K Casey Lion
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
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19
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Adidharma L, Bly RA, Theeuwen HA, Holdefer RN, Slimp J, Kinney GA, Martinez V, Whitlock KB, Perkins JA. Facial Nerve Branching Patterns Vary With Vascular Anomalies. Laryngoscope 2020; 130:2708-2713. [PMID: 31925962 DOI: 10.1002/lary.28500] [Citation(s) in RCA: 2] [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] [Received: 09/19/2019] [Revised: 12/06/2019] [Accepted: 12/11/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES At our institution, in vivo facial nerve mapping (FNM) is used during vascular anomaly (VAN) surgeries involving the facial nerve (FN) to create an FN map and prevent injury. During mapping, FN anatomy seemed to vary with VAN type. This study aimed to characterize FN branching patterns compared to published FN anatomy and VAN type. STUDY DESIGN Retrospective study of surgically relevant facial nerve anatomy. METHODS VAN patients (n = 67) with FN mapping between 2005 and 2018 were identified. Results included VAN type, FN relationship to VAN, FNM image with branch pattern, and surgical approach. A Fisher exact test compared FN relationships and surgical approach between VAN pathology, and FN branching types to published anatomical studies. MATLAB quantified FN branching with Euclidean distances and angles. Principal component analysis (PCA) and hierarchical cluster analysis (HCA) analyzed quantitative FN patterns amongst VAN types. RESULTS VANs included were hemangioma, venous malformation, lymphatic malformation, and arteriovenous malformation (n = 17, 13, 25, and 3, respectively). VAN FN patterns differed from described FN anatomy (P < .001). PCA and HCA in MATLAB-quantified FN branching demonstrated no patterns associated with VAN pathology (P = .80 and P = .91, one-way analysis of variance for principle component 1 (PC1) and priniciple component 2 (PC2), respectively). FN branches were usually adherent to hemangioma or venous malformation as compared to coursing through lymphatic malformation (both P = .01, Fisher exact). CONCLUSIONS FN branching patterns identified through electrical stimulation differ from cadaveric dissection determined FN anatomy. This reflects the high sensitivity of neurophysiologic testing in detecting small distal FN branches. Elongated FN branches traveling through lymphatic malformation may be related to abnormal nerve patterning in these malformations. LEVEL OF EVIDENCE NA Laryngoscope, 130:2708-2713, 2020.
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Affiliation(s)
- Lingga Adidharma
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Randall A Bly
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
| | - Hailey A Theeuwen
- University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Robert N Holdefer
- Neuromonitoring Program, Department of Rehabilitation, University of Washington, Seattle, Washington, U.S.A
| | - Jefferson Slimp
- Neuromonitoring Program, Department of Rehabilitation, University of Washington, Seattle, Washington, U.S.A
| | - Greg A Kinney
- Neuromonitoring Program, Department of Rehabilitation, University of Washington, Seattle, Washington, U.S.A
| | - Vicente Martinez
- Neuromonitoring Program, Department of Rehabilitation, University of Washington, Seattle, Washington, U.S.A
| | - Kathryn B Whitlock
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A
| | - Jonathan A Perkins
- Division of Pediatric Otolaryngology, Seattle Children's Hospital, Seattle, Washington, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, Washington, U.S.A
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20
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Holmer N, Artola E, Christianson E, Lynn AM, Whitlock KB, Norton S. Feasibility of Acupuncture to Induce Sleep for Brainstem Auditory Evoked Response Testing. Am J Audiol 2019; 28:895-907. [PMID: 31747523 DOI: 10.1044/2019_aja-19-0069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Purpose Brainstem auditory evoked response (BAER) testing is often performed under general anesthesia for children unable to complete behavioral audiologic evaluation. Alternatively, acupuncture treatment may be considered appropriate for BAER. Reports of acupuncture treatment in pediatric patients are scarce but are needed to demonstrate effectiveness. This study had 2 main objectives: (a) to examine the feasibility and effectiveness of acupuncture to achieve sleep to perform diagnostic BAER testing in medically complex (Cohort I) and nonmedically complex (Cohort II) children and (b) to assess acceptability to parents and audiologists of acupuncture as an alternative to anesthesia for BAER testing. Method A prospective feasibility study at Seattle Children's Hospital Outpatient Audiology Clinic from August 2015 through December 2018 was performed. A total of 31 pediatric patients were included. The median age for Cohort I was 29 months (interquartile range: 19-37 months), and the median age for Cohort II was 25.5 months (interquartile range: 16-32 months). Variables included number of BAER thresholds obtained, sleep indicators, and acceptability. The cost of BAER with acupuncture and the cost of BAER under anesthesia were compared. Results Acupuncture treatment effectively contributed to an adequate sleep state to obtain BAER results for most patients in both cohorts. Across cohorts, most patients (81%) fell asleep after acupuncture treatment. Complete test results were obtained in 48% of patients. Audiologists and parents reported high satisfaction rates with this procedure (87%). There were no adverse safety effects. Acupuncture treatment was less costly than anesthesia for BAER testing. Conclusions Acupuncture to induce sleep for BAER testing is effective, safe, and cost-efficient in small samples of medically and nonmedically complex pediatric patients. This procedure allowed earlier detection of hearing status and avoided potential adverse effects of anesthesia. Audiologists and parents reported that acupuncture treatment was an acceptable alternative to anesthesia for the BAER procedure.
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Affiliation(s)
- Nicole Holmer
- Division of Audiology, Seattle Children's Hospital, WA
| | - Elizabeth Artola
- Department of Anesthesia and Pain Medicine, Seattle Children's Hospital, WA
| | | | - Anne M. Lynn
- Department of Anesthesia and Pain Medicine, Seattle Children's Hospital, WA
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Kathryn B. Whitlock
- Department of Otolaryngology–Head and Neck Surgery, Seattle Children's Hospital, WA
- Center for Clinical and Translational Research, Seattle Children's Hospital, WA
| | - Susan Norton
- Division of Audiology, Seattle Children's Hospital, WA
- Childhood Communication Center, Seattle Children's Hospital, WA
- Department of Otolaryngology–Head and Neck Surgery, Seattle Children's Hospital, WA
- Department of Speech & Hearing Sciences, University of Washington, Seattle
- Department of Otolaryngology–Head and Neck Surgery, University of Washington, Seattle
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21
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Zenner K, Cheng CV, Jensen DM, Timms AE, Shivaram G, Bly R, Ganti S, Whitlock KB, Dobyns WB, Perkins J, Bennett JT. Genotype correlates with clinical severity in PIK3CA-associated lymphatic malformations. JCI Insight 2019; 4:129884. [PMID: 31536475 DOI: 10.1172/jci.insight.129884] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/12/2019] [Indexed: 12/19/2022] Open
Abstract
Lymphatic malformations (LMs) are congenital, nonneoplastic vascular malformations associated with postzygotic activating PIK3CA mutations. The mutation spectrum within LMs is narrow, with the majority having 1 of 3 hotspot mutations. Despite this relative genetic homogeneity, clinical presentations differ dramatically. We used molecular inversion probes and droplet digital polymerase chain reaction to perform deep, targeted sequencing of PIK3CA in 271 affected and unaffected tissue samples from 81 individuals with isolated LMs and retrospectively collected clinical data. Pathogenic PIK3CA mutations were identified in affected LM tissue in 64 individuals (79%) with isolated LMs, with variant allele fractions (VAFs) ranging from 0.1% to 13%. Initial analyses revealed no correlation between VAF and phenotype variables. Recognizing that different mutations activate PI3K to varying degrees, we developed a metric, the genotype-adjusted VAF (GVAF), to account for differences in mutation strength, and found significantly higher GVAFs in LMs with more severe clinical characteristics including orofacial location or microcystic structure. In addition to providing insight into LM pathogenesis, we believe GVAF may have broad applicability for genotype-phenotype analyses in mosaic disorders.
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Affiliation(s)
- Kaitlyn Zenner
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA.,Division of Pediatric Otolaryngology, Department of Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Chi Vicky Cheng
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Dana M Jensen
- Center For Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Andrew E Timms
- Center For Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington, USA
| | | | - Randall Bly
- Division of Pediatric Otolaryngology, Department of Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - Sheila Ganti
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - Kathryn B Whitlock
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington, USA
| | - William B Dobyns
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division Genetic Medicine, University of Washington, Seattle, Washington, USA
| | - Jonathan Perkins
- Division of Pediatric Otolaryngology, Department of Head and Neck Surgery, University of Washington, Seattle, Washington, USA
| | - James T Bennett
- Center For Developmental Biology and Regenerative Medicine, Seattle Children's Research Institute, Seattle, Washington, USA.,Department of Pediatrics, Division Genetic Medicine, University of Washington, Seattle, Washington, USA
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22
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Eisenberg-Guyot J, Moudon AV, Hurvitz PM, Mooney SJ, Whitlock KB, Saelens BE. Beyond the bus stop: where transit users walk. J Transp Health 2019; 14:100604. [PMID: 32832381 PMCID: PMC7442290 DOI: 10.1016/j.jth.2019.100604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
OBJECTIVES Extending the health benefits of public transit requires understanding how transit use affects pedestrian activity, including pedestrian activity not directly temporally or spatially related to transit use. In this study, we identified where transit users walked on transit days compared with non-transit days within and beyond 400m and 800m buffers surrounding their home and work addresses. METHODS We used data collected from 2008-2013 in King County, Washington, from 221 non-physically-disabled adult transit users, who were equipped with an accelerometer, global positioning system (GPS), and travel diary. We assigned walking activity to the following buffer locations: less than and at least 400m or 800m from home, work, or home/work (the home and work buffers comprised the latter buffer). We used Poisson generalized estimating equations to estimate differences in minutes per day of total walking and minutes per day of non-transit-related walking on transit days compared with non-transit days in each location. RESULTS We found that durations of total walking and non-transit-related walking were greater on transit days than on non-transit days in all locations studied. When considering the home neighborhood in isolation, most of the greater duration of walking occurred beyond the home neighborhood at both 400m and 800m; results were similar when considering the work neighborhood in isolation. When considering the neighborhoods jointly (i.e., by using the home/work buffer), at 400m, most of the greater duration of walking occurred beyond the home/work neighborhood. However, at 800m, most of the greater duration of walking occurred within the home/work neighborhood. CONCLUSIONS Transit days were associated with greater durations of total walking and non-transit related walking within and beyond the home and work neighborhoods. Accordingly, research, design, and policy strategies focused on transit use and pedestrian activity should consider locations outside the home and work neighborhoods, in addition to locations within them.
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Affiliation(s)
- Jerzy Eisenberg-Guyot
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
| | - Anne V. Moudon
- Urban Form Lab and Department of Urban Design and Planning, University of Washington College of Built Environments, Seattle, WA
| | - Philip M. Hurvitz
- Urban Form Lab and Department of Urban Design and Planning, University of Washington College of Built Environments, Seattle, WA
| | - Stephen J. Mooney
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA
- Harborview Injury Prevention & Research Center, Seattle, WA
| | | | - Brian E. Saelens
- Seattle Children’s Research Institute, Seattle, WA
- Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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23
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Chrisman SPD, Whitlock KB, Mendoza JA, Burton MS, Somers E, Hsu A, Fay L, Palermo TM, Rivara FP. Pilot Randomized Controlled Trial of an Exercise Program Requiring Minimal In-person Visits for Youth With Persistent Sport-Related Concussion. Front Neurol 2019; 10:623. [PMID: 31316446 PMCID: PMC6611408 DOI: 10.3389/fneur.2019.00623] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 03/19/2019] [Accepted: 05/28/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: To evaluate feasibility and acceptability of a sub-threshold exercise program with minimal in-person visits to treat youth with persistent sport-related concussion, and explore efficacy for improving concussive symptoms, health-related quality of life, and fear-avoidance. Study design: We conducted a pilot randomized controlled trial comparing a 6 week sub-threshold exercise program requiring only two in-person visits to active control (stretching) for 12-18 year old youth with persistent sport-related concussion. We measured moderate-to-vigorous physical activity pre- and post-intervention using accelerometry, and increased goals weekly via phone contact. We examined feasibility and acceptability using qualitative interviews. We used exponential regression to model differences in trajectory of concussive symptoms by experimental group, and linear regression to model differences in trajectory of health-related quality of life and fear-avoidance of pain by experimental group. Results: Thirty-two subjects randomized, 30 completed the study (n = 11 control, n = 19 intervention), 57% female. Youth and parents reported enjoying participating in the study and appreciated the structure and support, as well as the minimal in-person visits. Exponential regression modeling indicated that concussive symptoms declined more rapidly in intervention youth than control (p = 0.02). Health-related quality of life and fear-avoidance of pain improved over time, but were not significantly different by group. Conclusions: This study indicates feasibility and potential benefit of a 6 week subthreshold exercise program with minimal in-person visits for youth with persistent concussion. Potential factors that may play a role in improvement such as fear-avoidance deserve further study.
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Affiliation(s)
- Sara P D Chrisman
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention and Research Center, Seattle, WA, United States
| | - Kathryn B Whitlock
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Jason A Mendoza
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States
| | - Monique S Burton
- Department of Pediatrics, University of Washington, Seattle, WA, United States.,Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Ellie Somers
- Department of Sports Physical Therapy, Seattle Children's Hospital, Seattle, WA, United States
| | - Albert Hsu
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Lauren Fay
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States
| | - Tonya M Palermo
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, United States
| | - Frederick P Rivara
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, United States.,Department of Pediatrics, University of Washington, Seattle, WA, United States.,Harborview Injury Prevention and Research Center, Seattle, WA, United States
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Test MR, Whitlock KB, Langley M, Riva-Cambrin J, Kestle JRW, Simon TD. Relationship of causative organism and time to infection among children with cerebrospinal fluid shunt infection. J Neurosurg Pediatr 2019; 24:22-28. [PMID: 31051463 PMCID: PMC6928433 DOI: 10.3171/2019.2.peds18638] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [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: 11/01/2018] [Accepted: 02/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Infection is a common complication of cerebrospinal fluid (CSF) shunts, occurring in 6%-20% of children. Although studies are limited, Staphylococcus aureus is thought to cause more rapid and aggressive infection than coagulase-negative Staphylococcus (CONS) or gram-negative organisms. The authors' objective was to evaluate the relationship between the causative organisms of CSF shunt infection and the timing of infection. METHODS The authors performed a retrospective cohort study of children who underwent CSF shunt placement at a tertiary care children's hospital over a 9-year period and subsequently developed a CSF shunt infection. The primary predictor variable was the causative organism recovered from CSF culture, characterized as S. aureus, CONS, or gram-negative organisms. The primary outcome was time to infection, defined as the number of days from most recent shunt intervention to the diagnosis of the infection. The association between causative organism and time to infection was visualized using Kaplan-Meier curves, and statistical comparisons were made using nonparametric Kruskal-Wallis tests. RESULTS Among 103 children in whom a CSF shunt infection developed, the causative organism was CONS in 57 (55%), S. aureus in 19 (18%), and gram-negative organisms in 9 (9%). The median time to infection did not differ (p = 0.81) for infections caused by CONS (20 days, IQR 11-40), S. aureus (26 days, IQR 12-95), and gram-negative organisms (23 days, IQR 17-34). CONCLUSIONS No significant difference in time to infection based on the causative organism was observed among children with a CSF shunt infection.
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Affiliation(s)
- Matthew R. Test
- Department of Pediatrics, University of Washington/ Seattle Children’s Hospital, Seattle, Washington, United States
| | - Kathryn B. Whitlock
- Seattle Children’s Hospital Research Institute, Seattle, Washington, United States
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/ Primary Children’s Hospital (PCH), Salt Lake City, Utah, United States
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - John RW Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/ Primary Children’s Hospital (PCH), Salt Lake City, Utah, United States
| | - Tamara D. Simon
- Department of Pediatrics, University of Washington/ Seattle Children’s Hospital, Seattle, Washington, United States.,Seattle Children’s Hospital Research Institute, Seattle, Washington, United States
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Chrisman SPD, Whitlock KB, Kroshus E, Schwien C, Herring SA, Rivara FP. Parents' Perspectives Regarding Age Restrictions for Tackling in Youth Football. Pediatrics 2019; 143:peds.2018-2402. [PMID: 30936250 DOI: 10.1542/peds.2018-2402] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Accepted: 01/10/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In ice hockey and soccer, age restrictions exist for body checking and heading because of injury risk. There are currently no age restrictions for tackling in youth football. METHODS We surveyed a nationally representative sample of US parents regarding their support for age restrictions on tackling in football with responses of "yes," "no," and "maybe." We then generated regression models, attempting to predict support for age restrictions in tackling using demographic variables, parent perceptions of the risk of concussion in youth football, and the intensity of football support. All analyses were stratified by sex given effect modification. RESULTS There were 1025 parents who completed the survey (52% response rate; 56% female sex). The majority (61%) supported age restrictions for tackling, and an additional 24% indicated they maybe would support age restrictions. For female respondents, a greater perceived risk of tackle football (odds ratio [OR] 3.83; 95% confidence interval [CI] 1.06-13.83) and greater educational attainment (OR 3.97; 95% CI 1.61-9.80) were associated with greater odds of supporting age restrictions for tackling. For male respondents, having a child 6 to 12 years old was associated with greater odds of maybe supporting age restrictions for tackling (OR 2.34; 95% CI 1.19-4.62). CONCLUSIONS A majority of US parents across sexes would support age restrictions for tackling in football. This information should inform discussions when guidelines about tackling in youth football are revisited.
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Affiliation(s)
- Sara P D Chrisman
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Departments of.,Pediatrics.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Kathryn B Whitlock
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Departments of
| | - Emily Kroshus
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Departments of.,Pediatrics.,Harborview Injury Prevention and Research Center, Seattle, Washington
| | - Christina Schwien
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Departments of
| | - Stanley A Herring
- Harborview Injury Prevention and Research Center, Seattle, Washington.,Rehabilitation Medicine, Orthopedics and Sports Medicine, and Neurological Surgery, University of Washington, Seattle Washington; and
| | - Frederick P Rivara
- Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington; Departments of.,Pediatrics.,Harborview Injury Prevention and Research Center, Seattle, Washington
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Sathyanarayana S, Flynn JT, Messito MJ, Gross R, Whitlock KB, Kannan K, Karthikraj R, Morrison D, Huie M, Christakis D, Trasande L. Melamine and cyanuric acid exposure and kidney injury in US children. Environ Res 2019; 171:18-23. [PMID: 30641369 DOI: 10.1016/j.envres.2018.10.038] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 10/29/2018] [Accepted: 10/31/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Melamine and cyanuric acid, which are currently used in a variety of common consumer products and present in foods, have been implicated in the development of urolithiasis and acute kidney injury in Chinese children. To determine whether US children have measurable concentrations of these chemicals in their bodies and whether they are at greater risk of acute kidney injury, we measured melamine and cyanuric acid exposure in a cohort of US children and determined their relationship with markers of kidney injury. METHODS We measured urinary melamine and cyanuric acid in a convenience sample of 109 children (4 months - 8 years) from Seattle, WA and New York City, NY using liquid chromatography with tandem mass spectrometry. We measured several urinary markers of kidney injury: fatty acid binding protein 3 (FABP3), kidney injury molecule 1 (KIM1), neutrophil gelatinase-associated lipocalin (NGAL) using Luminex xMAP methods, and urine urea was measured using standard laboratory methods. We described urinary melamine and cyanuric acid concentrations and assessed predictors of the exposures. We used multivariable linear regression to assess relationships between melamine/cyanuric acid and kidney injury markers in unadjusted and adjusted (creatinine, age, sex) analyses. RESULTS Melamine and cyanuric acid were above the limit of detection (LOD) in 78% and 95% of all samples, respectively. The mean concentrations (SD) for melamine and cyanuric acid were 27.4 ng/ml (141.9 ng/ml) and 35.3 ng/ml (42.4 ng/ml). In unadjusted analyses, we observed statistically significant increases in the percentages of FABP3 and KIM1 in relation to a one log unit change in melamine and cyanuric acid, respectively. In adjusted analyses, we observed a 55% (95% CI 0, 141) increase in KIM1 in relation to a one log unit increase in cyanuric acid. CONCLUSIONS US children have detectable concentrations of melamine and cyanuric acid in urine, and these concentrations are higher than those reported in children from other countries. This is a novel finding that improves upon previous exposure estimates using questionnaires only and suggests widespread exposure in the population. Cyanuric acid is associated with increased KIM 1 concentrations, suggesting kidney injury. Given the potential widespread exposure, future analyses should examine melamine and cyanuric acid in relation to chronic kidney disease and markers of kidney injury in a larger cohort that is representative of the general population.
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Affiliation(s)
- Sheela Sathyanarayana
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, Division of General Pediatrics, University of Washington, Seattle, WA, USA; Department of Environmental and Occupational Health Sciences, Seattle, WA, USA.
| | - Joseph T Flynn
- Department of Pediatrics, Division of Nephrology, University of Washington, Seattle, WA, USA
| | - Mary Jo Messito
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Rachel Gross
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Kathryn B Whitlock
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA
| | | | | | - Debra Morrison
- Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Maryann Huie
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA
| | - Dimitri Christakis
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, WA, USA; Department of Pediatrics, Division of General Pediatrics, University of Washington, Seattle, WA, USA
| | - Leonardo Trasande
- Department of Pediatrics, New York University School of Medicine, New York, NY, USA; NYU Wagner School of Public Service, New York, NY, USA; Department of Nutrition, Food, and Public Health, NYU Steinhardt School of Culture, Education and Human Development, New York, NY, USA; NYU Global Institute of Public Health, New York University, New York, NY, USA
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Simon TD, Kronman MP, Whitlock KB, Browd SR, Holubkov R, Kestle JRW, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes WJ, Riva-Cambrin J, Rozzelle C, Shannon CN, Tamber M, Wellons JC, Whitehead WE, Mayer-Hamblett N. Reinfection rates following adherence to Infectious Diseases Society of America guideline recommendations in first cerebrospinal fluid shunt infection treatment. J Neurosurg Pediatr 2019; 23:1-9. [PMID: 30771757 DOI: 10.3171/2018.11.peds18373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVECSF shunt infection treatment requires both surgical and antibiotic decisions. Using the Hydrocephalus Clinical Research Network (HCRN) Registry and 2004 Infectious Diseases Society of America (IDSA) guidelines that were not proactively distributed to HCRN providers, the authors previously found high adherence to surgical recommendations but poor adherence to intravenous (IV) antibiotic duration recommendations. In general, IV antibiotic duration was longer than recommended. In March 2017, new IDSA guidelines expanded upon the 2004 guidelines by including recommendations for selection of specific antibiotics. The objective of this study was to describe adherence to both 2004 and 2017 IDSA guideline recommendations for CSF shunt infection treatment, and to report reinfection rates associated with adherence to guideline recommendations.METHODSThe authors investigated a prospective cohort of children younger than 18 years of age who underwent treatment for first CSF shunt infection at one of 7 hospitals from April 2008 to December 2012. CSF shunt infection was diagnosed by recovery of bacteria from CSF culture (CSF-positive infection). Adherence to 2004 and 2017 guideline recommendations was determined. Adherence to antibiotics was further classified as longer or shorter duration than guideline recommendations. Reinfection rates with 95% confidence intervals (CIs) were generated.RESULTSThere were 133 children with CSF-positive infections addressed by 2004 IDSA guideline recommendations, with 124 at risk for reinfection. Zero reinfections were observed among those whose treatment was fully adherent (0/14, 0% [95% CI 0%-20%]), and 15 reinfections were observed among those whose infection treatment was nonadherent (15/110, 14% [95% CI 8%-21%]). Among the 110 first infections whose infection treatment was nonadherent, 74 first infections were treated for a longer duration than guidelines recommended and 9 developed reinfection (9/74, 12% [95% CI 6%-22%]). There were 145 children with CSF-positive infections addressed by 2017 IDSA guideline recommendations, with 135 at risk for reinfection. No reinfections were observed among children whose treatment was fully adherent (0/3, 0% [95% CI 0%-64%]), and 18 reinfections were observed among those whose infection treatment was nonadherent (18/132, 14% [95% CI 8%-21%]).CONCLUSIONSThere is no clear evidence that either adherence to IDSA guidelines or duration of treatment longer than recommended is associated with reduction in reinfection rates. Because IDSA guidelines recommend shorter IV antibiotic durations than are typically used, improvement efforts to reduce IV antibiotic use in CSF shunt infection treatment can and should utilize IDSA guidelines.
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Affiliation(s)
- Tamara D Simon
- Departments of1Pediatrics and
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Matthew P Kronman
- Departments of1Pediatrics and
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Kathryn B Whitlock
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Samuel R Browd
- 3Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle
| | | | - John R W Kestle
- 5Division of Pediatric Neurosurgery, Primary Children's Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V Kulkarni
- 6Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Marcie Langley
- 5Division of Pediatric Neurosurgery, Primary Children's Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D Limbrick
- 7Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - Thomas G Luerssen
- 8Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - W Jerry Oakes
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - Jay Riva-Cambrin
- 5Division of Pediatric Neurosurgery, Primary Children's Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis Rozzelle
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - Chevis N Shannon
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - Mandeep Tamber
- 10Division of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
| | - John C Wellons
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - William E Whitehead
- 8Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nicole Mayer-Hamblett
- Departments of1Pediatrics and
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Simon TD, Kronman MP, Whitlock KB, Browd SR, Holubkov R, Kestle JRW, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes J, Riva-Cambrin J, Rozzelle C, Shannon CN, Tamber M, Wellons III JC, Whitehead WE, Mayer-Hamblett N. Patient and Treatment Characteristics by Infecting Organism in Cerebrospinal Fluid Shunt Infection. J Pediatric Infect Dis Soc 2018; 8:235-243. [PMID: 29771360 PMCID: PMC6601384 DOI: 10.1093/jpids/piy035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Previous studies of cerebrospinal fluid (CSF) shunt infection treatment have been limited in size and unable to compare patient and treatment characteristics by infecting organism. Our objective was to describe variation in patient and treatment characteristics for children with first CSF shunt infection, stratified by infecting organism subgroups outlined in the 2017 Infectious Disease Society of America's (IDSA) guidelines. METHODS We studied a prospective cohort of children <18 years of age undergoing treatment for first CSF shunt infection at one of 7 Hydrocephalus Clinical Research Network hospitals from April 2008 to December 2012. Differences between infecting organism subgroups were described using univariate analyses and Fisher's exact tests. RESULTS There were 145 children whose infections were diagnosed by CSF culture and addressed by IDSA guidelines, including 47 with Staphylococcus aureus, 52 with coagulase-negative Staphylococcus, 37 with Gram-negative bacilli, and 9 with Propionibacterium acnes. No differences in many patient and treatment characteristics were seen between infecting organism subgroups, including age at initial shunt, gender, race, insurance, indication for shunt, gastrostomy, tracheostomy, ultrasound, and/or endoscope use at all surgeries before infection, or numbers of revisions before infection. A larger proportion of infections were caused by Gram-negative bacilli when antibiotic-impregnated catheters were used at initial shunt placement (12 of 23, 52%) and/or subsequent revisions (11 of 23, 48%) compared with all other infections (9 of 68 [13%] and 13 of 68 [19%], respectively). No differences in reinfection were observed between infecting organism subgroups. CONCLUSIONS The organism profile encountered at infection differs when antibiotic-impregnated catheters are used, with a higher proportion of Gram-negative bacilli. This warrants further investigation given increasing adoption of antibiotic-impregnated catheters.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Washington,Seattle Children’s Research Institute, Washington,Correspondence: T. Simon, MD, MSPH, Associate Professor, University of Washington Department of Pediatrics, Division of Hospital Medicine, Seattle Children’s Research Institute Building 1, M/S JMB9, 1900 Ninth Avenue, Seattle, WA 98101 ()
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Washington,Seattle Children’s Research Institute, Washington
| | | | - Samuel R Browd
- Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Washington
| | | | - John R W Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City
| | - David D Limbrick
- Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in St. Louis, Missouri
| | - Thomas G Luerssen
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Jerry Oakes
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City,Present Affiliation: Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham
| | - Chevis N Shannon
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham,Present Affiliation: Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Mandeep Tamber
- Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania
| | - John C Wellons III
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham,Present Affiliation: Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Washington,Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Washington
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Simon TD, Kronman MP, Whitlock KB, Gove NE, Mayer-Hamblett N, Browd SR, Cochrane DD, Holubkov R, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes WJ, Riva-Cambrin J, Rozzelle C, Shannon C, Tamber M, Wellons JC, Whitehead WE, Kestle JRW. Reinfection after treatment of first cerebrospinal fluid shunt infection: a prospective observational cohort study. J Neurosurg Pediatr 2018; 21:346-358. [PMID: 29393813 PMCID: PMC5880734 DOI: 10.3171/2017.9.peds17112] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE CSF shunt infection requires both surgical and antibiotic treatment. Surgical treatment includes either total shunt removal with external ventricular drain (EVD) placement followed by new shunt insertion, or distal shunt externalization followed by new shunt insertion once the CSF is sterile. Antibiotic treatment includes the administration of intravenous antibiotics. The Hydrocephalus Clinical Research Network (HCRN) registry provides a unique opportunity to understand reinfection following treatment for CSF shunt infection. This study examines the association of surgical and antibiotic decisions in the treatment of first CSF shunt infection with reinfection. METHODS A prospective cohort study of children undergoing treatment for first CSF infection at 7 HCRN hospitals from April 2008 to December 2012 was performed. The HCRN consensus definition was used to define CSF shunt infection and reinfection. The key surgical predictor variable was surgical approach to treatment for CSF shunt infection, and the key antibiotic treatment predictor variable was intravenous antibiotic selection and duration. Cox proportional hazards models were constructed to address the time-varying nature of the characteristics associated with shunt surgeries. RESULTS Of 233 children in the HCRN registry with an initial CSF shunt infection during the study period, 38 patients (16%) developed reinfection over a median time of 44 days (interquartile range [IQR] 19-437). The majority of initial CSF shunt infections were treated with total shunt removal and EVD placement (175 patients; 75%). The median time between infection surgeries was 15 days (IQR 10-22). For the subset of 172 infections diagnosed by CSF culture, the mean ± SD duration of antibiotic treatment was 18.7 ± 12.8 days. In all Cox proportional hazards models, neither surgical approach to infection treatment nor overall intravenous antibiotic duration was independently associated with reinfection. The only treatment decision independently associated with decreased infection risk was the use of rifampin. While this finding did not achieve statistical significance, in all 5 Cox proportional hazards models both surgical approach (other than total shunt removal at initial CSF shunt infection) and nonventriculoperitoneal shunt location were consistently associated with a higher hazard of reinfection, while the use of ultrasound was consistently associated with a lower hazard of reinfection. CONCLUSIONS Neither surgical approach to treatment nor antibiotic duration was associated with reinfection risk. While these findings did not achieve statistical significance, surgical approach other than total removal at initial CSF shunt infection was consistently associated with a higher hazard of reinfection in this study and suggests the feasibility of controlling and standardizing the surgical approach (shunt removal with EVD placement). Considerably more variation and equipoise exists in the duration and selection of intravenous antibiotic treatment. Further consideration should be given to the use of rifampin in the treatment of CSF shunt infection. High-quality studies of the optimal duration of antibiotic treatment are critical to the creation of evidence-based guidelines for CSF shunt infection treatment.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital,Seattle Children's Research Institute, Seattle, Washington
| | - Matthew P. Kronman
- Department of Pediatrics, University of Washington/Seattle Children's Hospital,Seattle Children's Research Institute, Seattle, Washington
| | | | - Nancy E. Gove
- Seattle Children's Research Institute, Seattle, Washington
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children's Hospital,Seattle Children's Research Institute, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/Seattle Children's Hospital
| | - D. Douglas Cochrane
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | - Abhaya V. Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D. Limbrick
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - Thomas G. Luerssen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - W. Jerry Oakes
- Section of Pediatric Neurosurgery, Children's of Alabama, Division of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children's of Alabama, Division of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Chevis Shannon
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Mandeep Tamber
- Division of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
| | - John C. Wellons
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - John R. W. Kestle
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Malik FS, Yi-Frazier JP, Taplin CE, Roth CL, Whitlock KB, Howard W, Pihoker C. Improving the Care of Youth With Type 1 Diabetes With a Novel Medical-Legal Community Intervention: The Diabetes Community Care Ambassador Program. Diabetes Educ 2018; 44:168-177. [PMID: 29320934 DOI: 10.1177/0145721717750346] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The purpose of this study was to examine the feasibility and efficacy of the Diabetes Community Care Ambassador (DCCA) Program, a novel medical-legal community intervention designed to support high-risk youth with type 1 diabetes. Methods Study eligibility criteria: ages 3-19 years, A1C ≥8.5% (≥69 mmol/mol) and/or recent diabetic ketoacidosis hospitalization, type 1 diabetes duration ≥1 year, and English- or Spanish-speaking. Eighty-nine youth and their caregivers participated in the 9- to 12-month intervention, which included diabetes education and support through 3 home visits, 1 to 2 school visits, and phone support from a lay health worker, as well as legal support from a medical-legal partnership attorney. Feasibility was assessed; change in A1C was compared in a linear mixed model. Results Of the 89 DCCA Program participants, 80% completed the program, with the majority of participants rating their DCCA favorably. Sixty-two percent reported ≥1 unmet legal need, of whom 29% accepted legal counsel. Youth enrolled in the DCCA Program demonstrated an improvement in glycemic control as their mean A1C decreased from 9.71% (83 mmol/mol) at the start of the program to 9.40% (79 mmol/mol) at the end of the intervention period ( P = .03). Participants with public health insurance experienced the greatest differential A1C reduction (9.79% to 9.11%, 83 mmol/mol to 76 mmol/mol). Conclusions The DCCA Program represents a promising intervention for improving care of high-risk youth with type 1 diabetes. A significant proportion of caregivers of youth reported having an unmet legal need. Participants remained highly engaged and demonstrated improved glycemic control, particularly youth with public health insurance.
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Affiliation(s)
- Faisal S Malik
- Division of Endocrinology & Diabetes, Department of Pediatrics, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | | | - Craig E Taplin
- Division of Endocrinology & Diabetes, Department of Pediatrics, University of Washington, Seattle, Washington
| | - Christian L Roth
- Division of Endocrinology & Diabetes, Department of Pediatrics, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | | | - Waylon Howard
- Seattle Children's Research Institute, Seattle, Washington
| | - Catherine Pihoker
- Division of Endocrinology & Diabetes, Department of Pediatrics, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
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Simon TD, Whitlock KB, Haaland W, Wright DR, Zhou C, Neff J, Howard W, Cartin B, Mangione-Smith R. Effectiveness of a Comprehensive Case Management Service for Children With Medical Complexity. Pediatrics 2017; 140:peds.2017-1641. [PMID: 29192004 DOI: 10.1542/peds.2017-1641] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [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] [Accepted: 07/25/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs. METHODS Eligible CMC at Seattle Children's Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested. RESULTS Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5-9.8] vs 1.3 [95% CI: 1.9-4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701-$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year. CONCLUSIONS Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and .,Centers for Clinical and Translational Research and
| | - Kathryn B Whitlock
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Wren Haaland
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Davene R Wright
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - John Neff
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Waylon Howard
- Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
| | - Brian Cartin
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle Children's Hospital, Seattle, Washington; and.,Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington
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Chrisman SP, Whitlock KB, Somers E, Burton MS, Herring SA, Rowhani-Rahbar A, Rivara FP. Pilot study of the Sub-Symptom Threshold Exercise Program (SSTEP) for persistent concussion symptoms in youth. NeuroRehabilitation 2017; 40:493-499. [DOI: 10.3233/nre-161436] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Sara P.D. Chrisman
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
- Adolescent Medicine, University of Washington, Seattle, WA, USA
- Harborview Injury Prevention and Research Center Seattle, WA, USA
| | - Kathryn B. Whitlock
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
| | - Elissa Somers
- Department of Physical Therapy Seattle, Seattle Children’s Hospital, WA, USA
| | - Monique S. Burton
- Department of Pediatrics, Department of Orthopedics and Sports Medicine, Seattle Children’s Hospital, Seattle, WA, USA
| | - Stanley A. Herring
- University of Washington, Sports, Spine and Orthopedic Health, Seattle, WA, USA
| | | | - Frederick P. Rivara
- Seattle Children’s Research Institute, Center for Child Health, Behavior and Development, Seattle, WA, USA
- Harborview Injury Prevention and Research Center Seattle, WA, USA
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Schoenfelder E, Moreno M, Wilner M, Whitlock KB, Mendoza JA. Piloting a mobile health intervention to increase physical activity for adolescents with ADHD. Prev Med Rep 2017; 6:210-213. [PMID: 28373931 PMCID: PMC5374871 DOI: 10.1016/j.pmedr.2017.03.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 03/09/2017] [Accepted: 03/13/2017] [Indexed: 11/30/2022] Open
Abstract
Physical activity (PA) reduces symptoms of Attention Deficit Hyperactivity Disorder (ADHD); interventions to increase PA may improve functioning and health for adolescents with ADHD. Mobile health (mHealth) technology and social media constitute promising interactive modalities for engaging adolescents—who are at highest risk for ADHD treatment drop-out—in interventions to increase PA. The current pilot study evaluated feasibility and acceptability of an innovative intervention incorporating an mHealth-linked wearable activity tracker (Fitbit Flex) and a Facebook group to increase PA among adolescents with ADHD. 11 adolescents diagnosed with ADHD (age 14–18, m = 15.5; 54% female) participated in a 4-week trial utilizing the Fitbit Flex in conjunction with (1) weekly personalized step count goals (2) social support through a Facebook group and (3) daily text messages about PA. The study took place in the greater Seattle, Washington area in the fall of 2015. Adolescents completed online surveys twice per week to rate their ADHD symptoms and positive and negative mood states, and parents rated adolescent ADHD symptoms weekly. Participants were adherent to the study protocol and acceptability of the intervention was high. Linear mixed models indicated that participants significantly increased their average weekly steps over the course of the study and demonstrated improvements in both adolescent and parent-reported ADHD Inattentive symptoms. Results indicate that this mHealth intervention is engaging and promising for increasing PA among adolescents with ADHD, and warrant further study. Implications for improving ADHD symptoms and overall functioning for this undertreated population are discussed.
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Affiliation(s)
- Erin Schoenfelder
- Seattle Children's Research Institute, United States; University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences, United States; University of Washington School of Medicine, Department of Pediatrics, United States
| | - Megan Moreno
- Seattle Children's Research Institute, United States; University of Washington School of Medicine, Department of Pediatrics, United States
| | - Molly Wilner
- Touro College of Osteopathic Medicine, United States
| | | | - Jason A Mendoza
- Seattle Children's Research Institute, United States; University of Washington School of Medicine, Department of Pediatrics, United States
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Nandi-Munshi D, Afkarian M, Whitlock KB, Crandell JL, Bell RA, D’Agostino R, Saydah S, Mottl AK, Dabelea D, Black MH, Mayer-Davis EJ, Pihoker C. Vitamin D and Albuminuria in Youth with and without Type 1 Diabetes. Horm Res Paediatr 2017; 87:385-395. [PMID: 28554178 PMCID: PMC5568007 DOI: 10.1159/000475711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 01/27/2017] [Accepted: 04/12/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND/AIMS In adults, lower vitamin D has been associated with increased albuminuria. This association has not been extensively studied in youth with or without type 1 diabetes. METHODS We examined the cross-sectional association between vitamin D and albuminuria (urine albumin to creatinine ratio ≥30 mg/g) in 8,789 participants of the National Health and Nutrition Survey 2001-2006 (NHANES), who were 6-19 years old. Further, we examined the association between vitamin D and albuminuria in 938 participants from the SEARCH Nutritional Ancillary Study (SNAS), a longitudinal cohort of youth with type 1 diabetes. RESULTS Of the NHANES participants, 5.3, 19.5, and 53.7% had vitamin D levels <30, 50 and 80 nmol/L, respectively. Albuminuria was present in 12.8% and was more common in younger children, females, non-Hispanic whites, non-obese children, and children with hypertension. After adjustments, there was no association between vitamin D and albuminuria. Among the SNAS participants with type 1 diabetes, we also found no association between baseline vitamin D and subsequent albuminuria in unadjusted or adjusted analyses. CONCLUSION We did not find an association between serum vitamin D and albuminuria in either non-diabetic youth or those with type 1 diabetes. Further research is needed to more fully understand this relationship.
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Affiliation(s)
| | - Maryam Afkarian
- Nephrology Division, Department of Medicine, University of California, Davis, CA
| | - Kathryn B. Whitlock
- Core for Biomedical Statistics, Center for Clinical & Translational Research, Seattle Children’s Research Institute, Seattle, WA
| | - Jamie L. Crandell
- Department of Biostatistics and School of Nursing, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ronny A. Bell
- Department of Public Health, Brody School of Medicine, East Carolina University, Greenville, NC
| | - Ralph D’Agostino
- Department of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sharon Saydah
- Centers for Disease Control and Prevention, Division of Diabetes Translation
| | - Amy K. Mottl
- Division of Nephrology and Hypertension, University of North Carolina, Chapel Hill, NC
| | - Dana Dabelea
- Colorado School Of Public Health, University of Colorado Denver, Aurora, CO
| | | | - Elizabeth J Mayer-Davis
- Departments of Nutrition and Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Simon TD, Kronman MP, Whitlock KB, Gove N, Browd SR, Holubkov R, Kestle JR, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes J, Riva-Cambrin J, Rozzelle C, Shannon C, Tamber M, Wellons JC, Whitehead WE, Mayer-Hamblett N. Variability in Management of First Cerebrospinal Fluid Shunt Infection: A Prospective Multi-Institutional Observational Cohort Study. J Pediatr 2016; 179:185-191.e2. [PMID: 27692463 PMCID: PMC5123958 DOI: 10.1016/j.jpeds.2016.08.094] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [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: 05/07/2016] [Revised: 08/15/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe the variation in approaches to surgical and antibiotic treatment for first cerebrospinal fluid (CSF) shunt infection and adherence to Infectious Diseases Society of America (IDSA) guidelines. STUDY DESIGN We conducted a prospective cohort study of children undergoing treatment for first CSF infection at 7 Hydrocephalus Clinical Research Network hospitals from April 2008 through December 2012. Univariate analyses were performed to describe the study population. RESULTS A total of 151 children underwent treatment for first CSF shunt-related infection. Most children had undergone initial CSF shunt placement before the age of 6 months (n = 98, 65%). Median time to infection after shunt surgery was 28 days (IQR 15-52 days). Surgical management was most often shunt removal with interim external ventricular drain placement, followed by new shunt insertion (n = 122, 81%). Median time from first negative CSF culture to final surgical procedure was 14 days (IQR 10-21 days). Median duration of intravenous (IV) antibiotic use duration was 19 days (IQR 12-28 days). For 84 infections addressed by IDSA guidelines, 7 (8%) met guidelines and 61 (73%) had longer duration of IV antibiotic use than recommended. CONCLUSIONS Surgical treatment for infection frequently adheres to IDSA guidelines of shunt removal with external ventricular drain placement followed by new shunt insertion. However, duration of IV antibiotic use in CSF shunt infection treatment was consistently longer than recommended by the 2004 IDSA guidelines.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Matthew P. Kronman
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Kathryn B. Whitlock
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Nancy Gove
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - John R.W. Kestle
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D. Limbrick
- Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in Saint Louis, St. Louis, Missouri
| | - Thomas G. Luerssen
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jerry Oakes
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - Chevis Shannon
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - Mandeep Tamber
- Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - John C. Wellons
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
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Iorio ML, Menashe SJ, Iyer RS, Lewis SP, Steinman S, Whitlock KB, Tse RW. Glenohumeral Dysplasia Following Neonatal Brachial Plexus Palsy: Presentation and Predictive Features During Infancy. J Hand Surg Am 2015; 40:2345-51.e1. [PMID: 26541441 DOI: 10.1016/j.jhsa.2015.08.029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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: 04/03/2015] [Revised: 08/29/2015] [Accepted: 08/31/2015] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the presence and degree of glenohumeral dysplasia (GHD) in infants undergoing surgical exploration for neonatal brachial plexus palsy (NBPP) and to identify potential predictive factors of early maladaptive shoulder morphology. METHODS We included all consecutive patients with NBPP who underwent surgical exploration of their brachial plexus and who had a preoperative magnetic resonance imaging scan at our institution over a 3-year period. Demographic, therapy, and surgical data were collected. Imaging was reviewed for glenoid morphology, glenoid version, percent humeral head anterior to the scapula, and alpha angle. RESULTS Of 116 infants who presented to our institution during this 3-year period, 19 (16%) underwent surgical exploration and were included in the study. Median age at the time of the scan was 16 weeks (interquartile range, 14-46 weeks). Fourteen of 19 (74%) had GHD of Waters class 2 or increased malformation. Babies who had more severe palsies underwent earlier surgery and had less severe GHD at the time of surgery than did those with less severe palsies who had surgery later. Less severe GHD was associated with more severe palsies, as indicated by Narakas classification and number of root avulsions. Active external rotation was almost universally absent whereas other shoulder movements were present to varying degrees. More severe GHD was associated with greater total shoulder active range of motion and greater pectoralis major muscle mass. CONCLUSIONS Glenohumeral dysplasia occurs often and early in NBPP and may occur in the absence of restricted range of motion. Predictors include increasing age and factors related to muscular imbalance. As such, GHD likely affects the functional outcome that may be achieved with reinnervation, and early screening may improve outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Matthew L Iorio
- Division of Plastic Surgery, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA
| | - Sarah J Menashe
- Department of Radiology, Seattle Children's Hospital, Seattle, WA
| | - Ramesh S Iyer
- Department of Radiology, Seattle Children's Hospital, Seattle, WA
| | - Sarah P Lewis
- Department of Rehabilitation Medicine, Seattle Children's Hospital, Seattle, WA
| | - Suzanne Steinman
- Department of Orthopedics, Seattle Children's Hospital, Seattle, WA
| | - Kathryn B Whitlock
- Seattle Children's Research Institute, Seattle Children's Hospital, Seattle, WA
| | - Raymond W Tse
- Division of Plastic Surgery, Department of Surgery, Seattle Children's Hospital, Seattle, WA.
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Simon TD, Butler J, Whitlock KB, Browd SR, Holubkov R, Kestle JR, Kulkarni AV, Langley M, Limbrick DD, Mayer-Hamblett N, Tamber M, Wellons JC, Whitehead WE, Riva-Cambrin J. Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr 2014; 164:1462-8.e2. [PMID: 24661340 PMCID: PMC4035376 DOI: 10.1016/j.jpeds.2014.02.013] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [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: 10/02/2013] [Revised: 12/04/2013] [Accepted: 02/04/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To quantify the extent to which cerebrospinal fluid (CSF) shunt revisions are associated with increased risk of CSF shunt infection, after adjusting for patient factors that may contribute to infection risk. STUDY DESIGN We used the Hydrocephalus Clinical Research Network registry to assemble a large prospective 6-center cohort of 1036 children undergoing initial CSF shunt placement between April 2008 and January 2012. The primary outcome of interest was first CSF shunt infection. Data for initial CSF shunt placement and all subsequent CSF shunt revisions prior to first CSF shunt infection, where applicable, were obtained. The risk of first infection was estimated using a multivariable Cox proportional hazard model accounting for patient characteristics and CSF shunt revisions, and is reported using hazard ratios (HRs) with 95% CI. RESULTS Of the 102 children who developed first infection within 12 months of placement, 33 (32%) followed one or more CSF shunt revisions. Baseline factors independently associated with risk of first infection included: gastrostomy tube (HR 2.0, 95% CI, 1.1, 3.3), age 6-12 months (HR 0.3, 95% CI, 0.1, 0.8), and prior neurosurgery (HR 0.4, 95% CI, 0.2, 0.9). After controlling for baseline factors, infection risk was most significantly associated with the need for revision (1 revision vs none, HR 3.9, 95% CI, 2.2, 6.5; ≥2 revisions, HR 13.0, 95% CI, 6.5, 24.9). CONCLUSIONS This study quantifies the elevated risk of infection associated with shunt revisions observed in clinical practice. To reduce risk of infection risk, further work should optimize revision procedures.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/ Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Jerry Butler
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Kathryn B. Whitlock
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/ Seattle Children’s Hospital, Seattle, Washington
| | - Richard Holubkov
- Department of Neurosurgery, University of Washington/ Seattle Children’s Hospital, Seattle, Washington
| | - John R.W. Kestle
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D. Limbrick
- Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in Saint Louis, St. Louis, Missouri
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/ Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Mandeep Tamber
- Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - John C. Wellons
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama (during this work, currently at Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee)
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Simon TD, Mayer-Hamblett N, Whitlock KB, Langley M, Kestle JRW, Riva-Cambrin J, Rosenfeld M, Thorell EA. Few Patient, Treatment, and Diagnostic or Microbiological Factors, Except Complications and Intermittent Negative Cerebrospinal Fluid (CSF) Cultures During First CSF Shunt Infection, Are Associated With Reinfection. J Pediatric Infect Dis Soc 2014; 3:15-22. [PMID: 24567841 PMCID: PMC3933045 DOI: 10.1093/jpids/pit050] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [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: 11/01/2012] [Accepted: 06/06/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND The relationship between first and subsequent cerebrospinal fluid (CSF) shunt infections is poorly understood. By understanding the factors associated with increased risk of reinfection, researchers may provide optimal treatment strategies at the time of first infection. The objective of this study was to describe and compare children with and without CSF shunt reinfection. METHODS A retrospective cohort study was performed among 118 children who underwent initial CSF shunt placement and developed first CSF shunt infection. The primary outcome variable was CSF shunt reinfection. Patient risk factors and medical and surgical management of initial CSF shunt placement and first CSF shunt infection were compared between children with and without reinfection. RESULTS Of 118 children with first infection, 31 (26%) developed a reinfection during the study period (overall median follow-up, 2096 days). Factors associated with reinfection in this cohort included ventriculoatrial or complex shunt at initial CSF shunt placement, complications after first CSF shunt infection, and intermittent negative CSF cultures. CONCLUSIONS Few patient or treatment factors were associated with reinfection. Factors associated with difficult-to-treat first CSF shunt infection, including complications after first CSF shunt infection and intermittent negative CSF cultures, were associated with reinfection. Clinicians who treat patients with unusual CSF shunts or more difficult first infections should have a high index of suspicion for reinfection after treatment is completed.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, and,Center for Clinical and Translational Research, Seattle Children's Research Institute, Washington,Corresponding Author: Tamara Simon, MD, MSPH, Assistant Professor, University of Washington Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Research Institute Bldg 1, M/S C9S-9, 1900 Ninth Ave, Seattle, WA 98101. E-mail:
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, and,Center for Clinical and Translational Research, Seattle Children's Research Institute, Washington
| | - Kathryn B. Whitlock
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Washington
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Department of Neurosurgery
| | | | | | - Margaret Rosenfeld
- Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, and,Center for Clinical and Translational Research, Seattle Children's Research Institute, Washington
| | - Emily A. Thorell
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City
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Swanson JW, Avansino JR, Phillips GS, Yung D, Whitlock KB, Redding GJ, Sawin RS. Correlating Haller Index and cardiopulmonary disease in pectus excavatum. Am J Surg 2012; 203:660-664. [DOI: 10.1016/j.amjsurg.2011.12.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2011] [Revised: 12/14/2011] [Accepted: 12/14/2011] [Indexed: 11/29/2022]
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Simon TD, Whitlock KB, Riva-Cambrin J, Kestle JRW, Rosenfeld M, Dean JM, Holubkov R, Langley M, Mayer-Hamblett N. Association of intraventricular hemorrhage secondary to prematurity with cerebrospinal fluid shunt surgery in the first year following initial shunt placement. J Neurosurg Pediatr 2012; 9:54-63. [PMID: 22208322 PMCID: PMC3254255 DOI: 10.3171/2011.10.peds11307] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The neurosurgical literature has conflicting findings regarding the association between indications for CSF shunt placement and subsequent shunt surgery. The object of this study was to identify baseline factors at the time of initial CSF shunt placement that are independently associated with subsequent surgery. METHODS This was a retrospective cohort study of children ages 0-18 years who underwent initial CSF shunt placement between January 1, 1997, and October 12, 2006, at a tertiary care children's hospital. The outcome of interest was CSF shunt surgery (either for revision or infection) within 12 months after initial placement. Associations between subsequent CSF shunt surgery and indication for the initial shunt, adjusting for patient age and surgeon factors at the time of initial placement, were estimated using multivariate logistic regression. Medical and surgical decisions, which varied according to surgeon, were examined separately in a univariate analysis. RESULTS Of the 554 children in the study cohort, 233 (42%) underwent subsequent CSF shunt surgery, either for revision (167 patients [30%]) or infection (66 patients [12%]). In multivariate logistic regression modeling, significant risk factors for subsequent CSF shunt surgery included (compared with aqueductal stenosis) intraventricular hemorrhage (IVH) secondary to prematurity (adjusted odds ratio [AOR] 2.2, 95% CI 1.1-4.5) and other unusual indications (AOR 3.7, 95% CI 1.0-13.6). The patient's age at initial CSF shunt placement was not significantly associated with increased odds of subsequent surgery after adjusting for other associated factors. CONCLUSIONS The occurrence of IVH is associated with increased odds of subsequent CSF shunt surgery within 12 months after shunt placement. Families of and care providers for children with IVH should be attuned to their increased risk of shunt failure.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital,Seattle Children’s Hospital Research Institute, Seattle, Washington
| | | | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/PCMC
| | - John R. W. Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/PCMC
| | - Margaret Rosenfeld
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital,Seattle Children’s Hospital Research Institute, Seattle, Washington
| | - J. Michael Dean
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah/PCMC
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital,Seattle Children’s Hospital Research Institute, Seattle, Washington
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Carlozzi NE, Stout JC, Mills JA, Duff K, Beglinger LJ, Aylward EH, Whitlock KB, Solomon AC, Queller S, Langbehn DR, Johnson SA, Paulsen JS. Estimating premorbid IQ in the prodromal phase of a neurodegenerative disease. Clin Neuropsychol 2011; 25:757-77. [PMID: 21660882 PMCID: PMC3159182 DOI: 10.1080/13854046.2011.577811] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [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: 10/18/2022]
Abstract
Estimates of premorbid intellect are often used in neuropsychological assessment to make inferences about cognitive decline. To optimize the method of controlling for premorbid intellect in assessments of prodromal neurodegenerative disease, we examined performance on the American National Adult Reading Test (ANART; administered during Years 1 and 3) and the two-subtest version of the Wechsler Abbreviated Scale of Intelligence (WASI; administered in Years 2 and 4) in an ongoing prospective longitudinal study of 371 participants with prodromal Huntington disease and 51 participants with normal CAG repeats. Although both measures performed similarly, the ANART demonstrated slightly lower variability in performance over a 2-year period and had slightly higher test-retest reliability than the WASI.
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Affiliation(s)
- Noelle E. Carlozzi
- Department of Physical Medicine and Rehabilitation, University of Michigan, United States
| | - Julie C. Stout
- Department of Psychological and Brain Sciences, Indiana University, United States
- School of Psychology and Psychiatry, Monash University, Australia
| | - James A. Mills
- Department of Psychiatry, University of Iowa, United States
- Department of Biostatistics, University of Iowa, United States
| | - Kevin Duff
- Department of Neurology, University of Utah
| | | | | | - Kathryn B. Whitlock
- Department of Psychological and Brain Sciences, Indiana University, United States
| | - Andrea C. Solomon
- Department of Psychological and Brain Sciences, Indiana University, United States
| | - Sarah Queller
- Department of Psychological and Brain Sciences, Indiana University, United States
| | - Douglas R. Langbehn
- Department of Psychiatry, University of Iowa, United States
- Department of Biostatistics, University of Iowa, United States
| | | | - Jane S. Paulsen
- Department of Psychiatry, University of Iowa, United States
- Department of Neurology, University of Iowa, United States
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Stout JC, Paulsen JS, Queller S, Solomon AC, Whitlock KB, Campbell JC, Carlozzi N, Duff K, Beglinger LJ, Langbehn DR, Johnson SA, Biglan KM, Aylward EH. Neurocognitive signs in prodromal Huntington disease. Neuropsychology 2011; 25:1-14. [PMID: 20919768 PMCID: PMC3017660 DOI: 10.1037/a0020937] [Citation(s) in RCA: 271] [Impact Index Per Article: 20.8] [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: 11/08/2022] Open
Abstract
OBJECTIVE PREDICT-HD is a large-scale international study of people with the Huntington disease (HD) CAG-repeat expansion who are not yet diagnosed with HD. The objective of this study was to determine the stage in the HD prodrome at which cognitive differences from CAG-normal controls can be reliably detected. METHOD For each of 738 HD CAG-expanded participants, we computed estimated years to clinical diagnosis and probability of diagnosis in 5 years based on age and CAG-repeat expansion number (Langbehn, Brinkman, Falush, Paulsen, & Hayden, 2004). We then stratified the sample into groups: NEAR, estimated to be ≤9 years; MID, between 9 and 15 years; and FAR, ≥15 years. The control sample included 168 CAG-normal participants. Nineteen cognitive tasks were used to assess attention, working memory, psychomotor functions, episodic memory, language, recognition of facial emotion, sensory-perceptual functions, and executive functions. RESULTS Compared with the controls, the NEAR group showed significantly poorer performance on nearly all of the cognitive tests and the MID group on about half of the cognitive tests (p = .05, Cohen's d NEAR as large as -1.17, MID as large as -0.61). One test even revealed significantly poorer performance in the FAR group (Cohen's d = -0.26). Individual tasks accounted for 0.2% to 9.7% of the variance in estimated proximity to diagnosis. Overall, the cognitive battery accounted for 34% of the variance; in comparison, the Unified Huntington's Disease Rating Scale motor score accounted for 11.7%. CONCLUSIONS Neurocognitive tests are robust clinical indicators of the disease process prior to reaching criteria for motor diagnosis of HD.
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Affiliation(s)
- Julie C Stout
- School of Psychology, Psychiatry, and Psychological Medicine, Monash University, UT, USA
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