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Mayer AR, McQuaid JR, Wick TV, Dodd AB, Robertson-Benta CR, Stephenson DD, van der Horn HJ, Quinn DK, Davis WA, Hittson AK, Sapien RE, Phillips JP, Campbell RA. Sex- and Age-Related Differences in Post-Concussive Symptom Reporting Among Children and Their Parents. J Neurotrauma 2024; 41:209-221. [PMID: 37725586 PMCID: PMC11071089 DOI: 10.1089/neu.2023.0072] [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] [Indexed: 09/21/2023] Open
Abstract
Pediatric mild traumatic brain injury (pmTBI) has received increased public attention over the past decade, especially for children who experience persistent post-concussive symptoms (PCS). Common methods for obtaining pediatric PCS rely on both self- and parental report, exhibit moderate test-retest reliability, and variable child-parent agreement, and may yield high false positives. The current study investigated the impact of age and biological sex on PCS reporting (Post-Concussion Symptom Inventory) in patients with pmTBI (n = 286) at retrospective, 1 week, 4 months, and 1 year post-injury time points, as well as reported symptoms in healthy controls (HC; n = 218) at equivalent assessment times. HC and their parents reported higher PCS for their retrospective rating relative to the other three other study visits. Child-parent agreement was highest for female adolescents, but only approached acceptable ranges (≥ 0.75) immediately post-injury. Poor-to-fair child/parental agreement was observed for most other study visits for pmTBI and at all visits for HC. Parents rated female adolescents as being more symptomatic than their male counterparts in spite of small (pmTBI) or no (HC) sex-related differences in self-reported ratings, suggestive of a potential cultural bias in parental ratings. Test-retest reliability for self-report was typically below acceptable ranges for both pmTBI and HC groups, with reliability decreasing for HC and increasing for pmTBI as a function of time between visits. Parental test-retest reliability was higher for females. Although continued research is needed, current results support the use of child self-report over parental ratings for estimating PCS burden. Results also highlight the perils of relying on symptom self-report for diagnostic and prognostic purposes.
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Affiliation(s)
- Andrew R. Mayer
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, New Mexico, USA
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico, USA
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jessica R. McQuaid
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - Tracey V. Wick
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - Andrew B. Dodd
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - Cidney R. Robertson-Benta
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - David D. Stephenson
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - Harm J. van der Horn
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - Davin K. Quinn
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, New Mexico, USA
| | - William A. Davis
- Department of Orthopedics and Rehabilitation, University of New Mexico, Albuquerque, New Mexico, USA
| | - Anne K. Hittson
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - John P. Phillips
- The Mind Research Network/Lovelace Biomedical and Environmental Research Institute, Albuquerque, New Mexico, USA
- Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Richard A. Campbell
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, New Mexico, USA
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van der Horn HJ, Ling JM, Wick TV, Dodd AB, Robertson-Benta CR, McQuaid JR, Zotev V, Vakhtin AA, Ryman SG, Cabral J, Phillips JP, Campbell RA, Sapien RE, Mayer AR. Dynamic Functional Connectivity in Pediatric Mild Traumatic Brain Injury. Neuroimage 2024; 285:120470. [PMID: 38016527 PMCID: PMC10815936 DOI: 10.1016/j.neuroimage.2023.120470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 11/13/2023] [Accepted: 11/20/2023] [Indexed: 11/30/2023] Open
Abstract
Resting-state fMRI can be used to identify recurrent oscillatory patterns of functional connectivity within the human brain, also known as dynamic brain states. Alterations in dynamic brain states are highly likely to occur following pediatric mild traumatic brain injury (pmTBI) due to the active developmental changes. The current study used resting-state fMRI to investigate dynamic brain states in 200 patients with pmTBI (ages 8-18 years, median = 14 years) at the subacute (∼1-week post-injury) and early chronic (∼ 4 months post-injury) stages, and in 179 age- and sex-matched healthy controls (HC). A k-means clustering analysis was applied to the dominant time-varying phase coherence patterns to obtain dynamic brain states. In addition, correlations between brain signals were computed as measures of static functional connectivity. Dynamic connectivity analyses showed that patients with pmTBI spend less time in a frontotemporal default mode/limbic brain state, with no evidence of change as a function of recovery post-injury. Consistent with models showing traumatic strain convergence in deep grey matter and midline regions, static interhemispheric connectivity was affected between the left and right precuneus and thalamus, and between the right supplementary motor area and contralateral cerebellum. Changes in static or dynamic connectivity were not related to symptom burden or injury severity measures, such as loss of consciousness and post-traumatic amnesia. In aggregate, our study shows that brain dynamics are altered up to 4 months after pmTBI, in brain areas that are known to be vulnerable to TBI. Future longitudinal studies are warranted to examine the significance of our findings in terms of long-term neurodevelopment.
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Affiliation(s)
| | - Josef M Ling
- The Mind Research Network/LBERI, Albuquerque, NM 87106
| | - Tracey V Wick
- The Mind Research Network/LBERI, Albuquerque, NM 87106
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM 87106
| | | | | | - Vadim Zotev
- The Mind Research Network/LBERI, Albuquerque, NM 87106
| | | | | | - Joana Cabral
- Life and Health Sciences Research Institute, University of Minho, Braga, Portugal
| | | | - Richard A Campbell
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131
| | - Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM 87106; Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131; Department of Psychology, University of New Mexico, Albuquerque, NM 87131; Department of Neurology, University of New Mexico, Albuquerque, NM 87131
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Mayer AR, Dodd AB, Robertson-Benta CR, Zotev V, Ryman SG, Meier TB, Campbell RA, Phillips JP, van der Horn HJ, Hogeveen J, Tarawneh R, Sapien RE. Multifaceted neural and vascular pathologies after pediatric mild traumatic brain injury. J Cereb Blood Flow Metab 2024; 44:118-130. [PMID: 37724718 PMCID: PMC10905640 DOI: 10.1177/0271678x231197188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 06/01/2023] [Accepted: 07/25/2023] [Indexed: 09/21/2023]
Abstract
Dynamic changes in neurodevelopment and cognitive functioning occur during adolescence, including a switch from reactive to more proactive forms of cognitive control, including response inhibition. Pediatric mild traumatic brain injury (pmTBI) affects these cognitions immediately post-injury, but the role of vascular versus neural injury in cognitive dysfunction remains debated. This study consecutively recruited 214 sub-acute pmTBI (8-18 years) and age/sex-matched healthy controls (HC; N = 186), with high retention rates (>80%) at four months post-injury. Multimodal imaging (functional MRI during response inhibition, cerebral blood flow and cerebrovascular reactivity) assessed for pathologies within the neurovascular unit. Patients exhibited increased errors of commission and hypoactivation of motor circuitry during processing of probes. Evidence of increased/delayed cerebrovascular reactivity within motor circuitry during hypercapnia was present along with normal perfusion. Neither age-at-injury nor post-concussive symptom load were strongly associated with imaging abnormalities. Collectively, mild cognitive impairments and clinical symptoms may continue up to four months post-injury. Prolonged dysfunction within the neurovascular unit was observed during proactive response inhibition, with preliminary evidence that neural and pure vascular trauma are statistically independent. These findings suggest pmTBI is characterized by multifaceted pathologies during the sub-acute injury stage that persist several months post-injury.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Vadim Zotev
- The Mind Research Network/LBERI, Albuquerque, NM, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard A Campbell
- Department of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | | | - Jeremy Hogeveen
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
| | - Rawan Tarawneh
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
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van der Horn HJ, Dodd AB, Wick TV, Robertson‐Benta CR, McQuaid JR, Hittson AK, Ling JM, Zotev V, Ryman SG, Erhardt EB, Phillips JP, Campbell RA, Sapien RE, Mayer AR. Neural correlates of cognitive control deficits in pediatric mild traumatic brain injury. Hum Brain Mapp 2023; 44:6173-6184. [PMID: 37800467 PMCID: PMC10619369 DOI: 10.1002/hbm.26504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/18/2023] [Accepted: 09/14/2023] [Indexed: 10/07/2023] Open
Abstract
There is a growing body of research showing that cerebral pathophysiological processes triggered by pediatric mild traumatic brain injury (pmTBI) may extend beyond the usual clinical recovery timeline. It is paramount to further unravel these processes, because the possible long-term cognitive effects resulting from ongoing secondary injury in the developing brain are not known. In the current fMRI study, neural processes related to cognitive control were studied in 181 patients with pmTBI at sub-acute (SA; ~1 week) and early chronic (EC; ~4 months) stages post-injury. Additionally, a group of 162 age- and sex-matched healthy controls (HC) were recruited at equivalent time points. Proactive (post-cue) and reactive (post-probe) cognitive control were examined using a multimodal attention fMRI paradigm for either congruent or incongruent stimuli. To study brain network function, the triple-network model was used, consisting of the executive and salience networks (collectively known as the cognitive control network), and the default mode network. Additionally, whole-brain voxel-wise analyses were performed. Decreased deactivation was found within the default mode network at the EC stage following pmTBI during both proactive and reactive control. Voxel-wise analyses revealed sub-acute hypoactivation of a frontal area of the cognitive control network (left pre-supplementary motor area) during proactive control, with a reversed effect at the EC stage after pmTBI. Similar effects were observed in areas outside of the triple-network during reactive control. Group differences in activation during proactive control were limited to the visual domain, whereas for reactive control findings were more pronounced during the attendance of auditory stimuli. No significant correlations were present between task-related activations and (persistent) post-concussive symptoms. In aggregate, current results show alterations in neural functioning during cognitive control in pmTBI up to 4 months post-injury, regardless of clinical recovery. We propose that subacute decreases in activity reflect a general state of hypo-excitability due to the injury, while early chronic hyperactivation represents a compensatory mechanism to prevent default mode interference and to retain cognitive control.
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Affiliation(s)
| | | | | | | | | | | | - Josef M. Ling
- The Mind Research Network/LBERIAlbuquerqueNew MexicoUSA
| | - Vadim Zotev
- The Mind Research Network/LBERIAlbuquerqueNew MexicoUSA
| | | | - Erik B. Erhardt
- Department of Mathematics and StatisticsUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | | | - Richard A. Campbell
- Department of Psychiatry & Behavioral SciencesUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Robert E. Sapien
- Department of Emergency MedicineUniversity of New MexicoAlbuquerqueNew MexicoUSA
| | - Andrew R. Mayer
- The Mind Research Network/LBERIAlbuquerqueNew MexicoUSA
- Department of Psychiatry & Behavioral SciencesUniversity of New MexicoAlbuquerqueNew MexicoUSA
- Department of PsychologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
- Department of NeurologyUniversity of New MexicoAlbuquerqueNew MexicoUSA
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Mayer AR, Meier TB, Dodd AB, Stephenson DD, Robertson-Benta CR, Ling JM, Pabbathi Reddy S, Zotev V, Vakamudi K, Campbell RA, Sapien RE, Erhardt EB, Phillips JP, Vakhtin AA. Prospective Study of Gray Matter Atrophy Following Pediatric Mild Traumatic Brain Injury. Neurology 2023; 100:e516-e527. [PMID: 36522161 PMCID: PMC9931084 DOI: 10.1212/wnl.0000000000201470] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 03/18/2022] [Accepted: 09/09/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The clinical and physiologic time course for recovery following pediatric mild traumatic brain injury (pmTBI) remains actively debated. The primary objective of the current study was to prospectively examine structural brain changes (cortical thickness and subcortical volumes) and age-at-injury effects. A priori study hypotheses predicted reduced cortical thickness and hippocampal volumes up to 4 months postinjury, which would be inversely associated with age at injury. METHODS Prospective cohort study design with consecutive recruitment. Study inclusion adapted from American Congress of Rehabilitation Medicine (upper threshold) and Zurich Concussion in Sport Group (minimal threshold) and diagnosed by Emergency Department and Urgent Care clinicians. Major neurologic, psychiatric, or developmental disorders were exclusionary. Clinical (Common Data Element) and structural (3 T MRI) evaluations within 11 days (subacute visit [SA]) and at 4 months (early chronic visit [EC]) postinjury. Age- and sex-matched healthy controls (HC) to control for repeat testing/neurodevelopment. Clinical outcomes based on self-report and cognitive testing. Structural images quantified with FreeSurfer (version 7.1.1). RESULTS A total of 208 patients with pmTBI (age = 14.4 ± 2.9; 40.4% female) and 176 HC (age = 14.2 ± 2.9; 42.0% female) were included in the final analyses (>80% retention). Reduced cortical thickness (right rostral middle frontal gyrus; d = -0.49) and hippocampal volumes (d = -0.24) observed for pmTBI, but not associated with age at injury. Hippocampal volume recovery was mediated by loss of consciousness/posttraumatic amnesia. Significantly greater postconcussive symptoms and cognitive deficits were observed at SA and EC visits, but were not associated with the structural abnormalities. Structural abnormalities slightly improved balanced classification accuracy above and beyond clinical gold standards (∆+3.9%), with a greater increase in specificity (∆+7.5%) relative to sensitivity (∆+0.3%). DISCUSSION Current findings indicate that structural brain abnormalities may persist up to 4 months post-pmTBI and are partially mediated by initial markers of injury severity. These results contribute to a growing body of evidence suggesting prolonged physiologic recovery post-pmTBI. In contrast, there was no evidence for age-at-injury effects or physiologic correlates of persistent symptoms in our sample.
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Affiliation(s)
- Andrew R Mayer
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque.
| | - Timothy B Meier
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Andrew B Dodd
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - David D Stephenson
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Cidney R Robertson-Benta
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Josef M Ling
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Sharvani Pabbathi Reddy
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Vadim Zotev
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Kishore Vakamudi
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Richard A Campbell
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Robert E Sapien
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Erik B Erhardt
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - John P Phillips
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
| | - Andrei A Vakhtin
- From the The Mind Research Network/Lovelace Biomedical Research Institute (A.R.M., A.B.D., D.D.S., C.R.R.-B., J.M.L., S.P.R., V.Z., K.V., J.P.P., A.A.V.); Department of Psychology (A.R.M.), Department of Neurology (A.R.M., J.P.P.), and Department of Psychiatry & Behavioral Sciences (A.R.M., R.A.C.), University of New Mexico, Albuquerque; Department of Neurosurgery (T.B.M.), Department of Cell Biology, Neurobiology and Anatomy (T.B.M.), and Department of Biomedical Engineering (T.B.M.), Medical College of Wisconsin, Milwaukee; and Department of Emergency Medicine (R.E.S.), and Department of Mathematics and Statistics (E.B.E.), University of New Mexico, Albuquerque
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Mayer AR, Ling JM, Dodd AB, Stephenson DD, Pabbathi Reddy S, Robertson-Benta CR, Erhardt EB, Harms RL, Meier TB, Vakhtin AA, Campbell RA, Sapien RE, Phillips JP. Multicompartmental models and diffusion abnormalities in paediatric mild traumatic brain injury. Brain 2022; 145:4124-4137. [PMID: 35727944 DOI: 10.1093/brain/awac221] [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: 11/23/2021] [Revised: 04/29/2022] [Accepted: 06/09/2022] [Indexed: 01/23/2023] Open
Abstract
The underlying pathophysiology of paediatric mild traumatic brain injury and the time-course for biological recovery remains widely debated, with clinical care principally informed by subjective self-report. Similarly, clinical evidence indicates that adolescence is a risk factor for prolonged recovery, but the impact of age-at-injury on biomarkers has not been determined in large, homogeneous samples. The current study collected diffusion MRI data in consecutively recruited patients (n = 203; 8-18 years old) and age and sex-matched healthy controls (n = 170) in a prospective cohort design. Patients were evaluated subacutely (1-11 days post-injury) as well as at 4 months post-injury (early chronic phase). Healthy participants were evaluated at similar times to control for neurodevelopment and practice effects. Clinical findings indicated persistent symptoms at 4 months for a significant minority of patients (22%), along with residual executive dysfunction and verbal memory deficits. Results indicated increased fractional anisotropy and reduced mean diffusivity for patients, with abnormalities persisting up to 4 months post-injury. Multicompartmental geometric models indicated that estimates of intracellular volume fractions were increased in patients, whereas estimates of free water fractions were decreased. Critically, unique areas of white matter pathology (increased free water fractions or increased neurite dispersion) were observed when standard assumptions regarding parallel diffusivity were altered in multicompartmental models to be more biologically plausible. Cross-validation analyses indicated that some diffusion findings were more reproducible when ∼70% of the total sample (142 patients, 119 controls) were used in analyses, highlighting the need for large-sample sizes to detect abnormalities. Supervised machine learning approaches (random forests) indicated that diffusion abnormalities increased overall diagnostic accuracy (patients versus controls) by ∼10% after controlling for current clinical gold standards, with each diffusion metric accounting for only a few unique percentage points. In summary, current results suggest that novel multicompartmental models are more sensitive to paediatric mild traumatic brain injury pathology, and that this sensitivity is increased when using parameters that more accurately reflect diffusion in healthy tissue. Results also indicate that diffusion data may be insufficient to achieve a high degree of objective diagnostic accuracy in patients when used in isolation, which is to be expected given known heterogeneities in pathophysiology, mechanism of injury and even criteria for diagnoses. Finally, current results indicate ongoing clinical and physiological recovery at 4 months post-injury.
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Affiliation(s)
- Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA.,Department of Psychology, University of New Mexico, Albuquerque, NM 87131, USA.,Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA.,Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Josef M Ling
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA
| | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA
| | | | | | | | - Erik B Erhardt
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque, NM 87131, USA
| | | | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA.,Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI 53226, USA.,Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | | | - Richard A Campbell
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM 87131, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM 87131, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, NM 87106, USA.,Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
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7
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Sicard V, Stephenson DD, Hergert DC, Dodd AB, Robertson-Benta CR, Reddy SP, Yeates KO, Cromer JA, Meier TB, Campbell RA, Phillips JP, Sapien RE, Mayer AR. Investigating the diagnostic accuracy of a paper-and-pencil and a computerized cognitive test battery for pediatric mild traumatic brain injury. Neuropsychology 2022; 36:565-577. [PMID: 35377682 PMCID: PMC9900695 DOI: 10.1037/neu0000803] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE This study assessed classification accuracy of paper-and-pencil and computerized cognitive batteries at subacute (SA; 1-11 days) and early chronic (EC; ∼4 months) phases of pediatric mild traumatic brain injury (pmTBI). Two statistical approaches focused on single-subject performance (individual task scores, total impairments) were used to maximize clinical utility. METHOD Two hundred thirty-five pmTBI and 169 healthy controls (HC) participants aged 8-18 were enrolled, with a subset (190 pmTBI; 160 HC) returning for the EC visit. The paper-and-pencil battery included several neuropsychological tests selected from recommended common data elements, whereas computerized testing was performed with the Cogstate Brief Battery. Hierarchical logistic regressions (base model: Parental education and premorbid reading abilities; full model: Base model and cognitive testing variables) were used to examine sensitivity/specificity, with diagnosis as the dependent variable. RESULTS Number Sequencing and Cogstate One-Card Learning accuracy significantly predicted SA diagnosis (full model accuracy = 71.6%-71.7%, sensitivity = 80.6%-80.8%, specificity = 59.1%-59.6%), while only immediate recall was significant at EC visit (accuracy = 68.5%, sensitivity = 74.6%, specificity = 61.5%). Other measures (Letter Fluency, Cogstate Detection, and One-Card Learning accuracy) demonstrated higher proportions of impairment for pmTBI subacutely (pmTBI: 11.5%-19.8%; HC: 3.7%-6.1%) but did not improve classification accuracy. Evidence of multiple impairments across the entire testing battery significantly predicted diagnosis at both visits (full model accuracy = 66.2%-68.6%, sensitivity = 71.2%-78.9%, specificity = 54.3%-61.5%). CONCLUSIONS Current results suggest similar modest diagnostic accuracy for computerized and paper-and-pencil batteries across multiple pmTBI phases. Moreover, findings suggest the total number of impairments may be more clinically useful than any single test or cognitive domain in terms of diagnostic accuracy at both assessment points. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
- Veronik Sicard
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - David D. Stephenson
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - Danielle C. Hergert
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - Andrew B. Dodd
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | | | | | - Keith Owen Yeates
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
- Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason A. Cromer
- Child Study Center, Yale University, New Haven, CT, USA
- Cogstate Ltd, New Haven, CT, USA
| | - Timothy B. Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, WI, USA
- Department of Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard A. Campbell
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
| | - John P. Phillips
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
| | - Robert E. Sapien
- Department of Emergency Medicine University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Andrew R. Mayer
- The Mind Research Network/Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, Albuquerque, NM, USA
- Department of Psychology, University of New Mexico, Albuquerque, NM, USA
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Levine AC, O’Connell KJ, Schnadower D, VanBuren TJM, Mahajan P, Hurley KF, Tarr P, Olsen CS, Poonai N, Schuh S, Powell EC, Farion KJ, Sapien RE, Roskind CG, Rogers AJ, Bhatt S, Gouin S, Vance C, Freedman SB. Derivation of the Pediatric Acute Gastroenteritis Risk Score to Predict Moderate-to-Severe Acute Gastroenteritis. J Pediatr Gastroenterol Nutr 2022; 74:446-453. [PMID: 35129163 PMCID: PMC9203936 DOI: 10.1097/mpg.0000000000003395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Although most acute gastroenteritis (AGE) episodes in children rapidly self-resolve, some children go on to experience more significant and prolonged illness. We sought to develop a prognostic score to identify children at risk of experiencing moderate-to-severe disease after an index emergency department (ED) visit. METHODS Data were collected from a cohort of children 3 to 48 months of age diagnosed with AGE in 16 North American pediatric EDs. Moderate-to-severe AGE was defined as a Modified Vesikari Scale (MVS) score ≥9 during the 14-day post-ED visit. A clinical prognostic model was derived using multivariable logistic regression and converted into a simple risk score. The model's accuracy was assessed for moderate-to-severe AGE and several secondary outcomes. RESULTS After their index ED visit, 19% (336/1770) of participants developed moderate-to-severe AGE. Patient age, number of vomiting episodes, dehydration status, prior ED visits, and intravenous rehydration were associated with MVS ≥9 in multivariable regression. Calibration of the prognostic model was strong with a P value of 0.77 by the Hosmer-Lemenshow goodness-of-fit test, and discrimination was moderate with an area under the receiver operator characteristic curve of 0.68 (95% confidence interval [CI] 0.65-0.72). Similarly, the model was shown to have good calibration when fit to the secondary outcomes of subsequent ED revisit, intravenous rehydration, or hospitalization within 72 hours after the index visit. CONCLUSIONS After external validation, this new risk score may provide clinicians with accurate prognostic insight into the likely disease course of children with AGE, informing disposition decisions, anticipatory guidance, and follow-up care.
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Affiliation(s)
- Adam C. Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children’s Hospital and Brown University, Providence, RI
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children’s National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | | | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan
- Wayne State University, Detroit
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Katrina F. Hurley
- Department of Emergency Medicine, IWK Health, Halifax, Nova Scotia, Canada
| | - Phillip Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Naveen Poonai
- Departments of Pediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry
- Children’s Health Research Institute, London Health Sciences Centre, London
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, SickKids Research Institute, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University, Chicago, IL
| | - Ken J. Farion
- Departments of Pediatrics and Emergency Medicine, University of Ottawa
- Pediatric Emergency Department, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Cindy G. Roskind
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI
| | - Seema Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Serge Gouin
- Departments of Pediatric Emergency Medicine & Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Cheryl Vance
- Departments of Pediatrics and Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA
| | - Stephen B. Freedman
- Divisions of Pediatric Emergency Medicine and Gastroenterology, Alberta, Children’s Hospital, Alberta, Canada
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB
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Roskind CG, Schnadower D, Olsen CS, Casper TC, Tarr PI, O’Connell KJ, Levine AC, Poonai N, Schuh S, Rogers AJ, Bhatt SR, Gouin S, Mahajan P, Vance C, Hurley K, Farion KJ, Sapien RE, Freedman SB, Freedman SB. Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis. Ann Emerg Med 2022; 79:66-74. [PMID: 34389195 PMCID: PMC8712362 DOI: 10.1016/j.annemergmed.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice. METHODS This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit. RESULTS In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ. CONCLUSION Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.
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Affiliation(s)
- Cindy G. Roskind
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, and Department of Pediatrics, University of Cincinnati College of Medicine, OHIO, USA
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - T. Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Phillip I. Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Adam C. Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence, RI, USA
| | - Naveen Poonai
- Department of Pediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, London, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto and Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Seema R. Bhatt
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Serge Gouin
- Department of Pediatric Emergency Medicine, Centre Hospital Universitaire (CHU) Ste-Justine, Université de Montréal, Montreal, Canada
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA, and Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Cheryl Vance
- Departments of Pediatrics and Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Katrina Hurley
- Division of Pediatric Emergency Medicine, IWK Health Center, Halifax, NS, Canada
| | - Ken J. Farion
- Departments of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Ketai LH, Komesu YM, Schrader RM, Rogers RG, Sapien RE, Dodd AB, Mayer AR. Mind-body (hypnotherapy) treatment of women with urgency urinary incontinence: changes in brain attentional networks. Am J Obstet Gynecol 2021; 224:498.e1-498.e10. [PMID: 33122028 PMCID: PMC10739935 DOI: 10.1016/j.ajog.2020.10.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/02/2020] [Accepted: 10/23/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Prior study of patients with urgency urinary incontinence by functional magnetic resonance imaging showed altered function in areas of the brain associated with interoception and salience and with attention. Our randomized controlled trial of hypnotherapy for urgency urinary incontinence demonstrated marked improvement in urgency urinary incontinence symptoms at 2 months. A subsample of these women with urgency urinary incontinence underwent functional magnetic resonance imaging before and after treatment. OBJECTIVE This study aimed to determine if hypnotherapy treatment of urgency urinary incontinence compared with pharmacotherapy was associated with altered brain activation or resting connectivity on functional magnetic resonance imaging. STUDY DESIGN A subsample of women participating in a randomized controlled trial comparing hypnotherapy vs pharmacotherapy for treatment of urgency urinary incontinence was evaluated with functional magnetic resonance imaging. Scans were obtained pretreatment and 8 to 12 weeks after treatment initiation. Brain activation during bladder filling and resting functional connectivity with an empty and partially filled bladder were assessed. Brain regions of interest were derived from those previously showing differences between healthy controls and participants with untreated urgency urinary incontinence in our prior work and included regions in the interoceptive and salience, ventral attentional, and dorsal attentional networks. RESULTS After treatment, participants in both groups demonstrated marked improvement in incontinence episodes (P<.001). Bladder-filling task functional magnetic resonance imaging data from the combined groups (n=64, 30 hypnotherapy, 34 pharmacotherapy) demonstrated decreased activation of the left temporoparietal junction, a component of the ventral attentional network (P<.01) compared with baseline. Resting functional connectivity differed only with the bladder partially filled (n=54). Compared with pharmacotherapy, hypnotherapy participants manifested increased functional connectivity between the anterior cingulate cortex and the left dorsolateral prefrontal cortex, a component of the dorsal attentional network (P<.001). CONCLUSION Successful treatment of urgency urinary incontinence with both pharmacotherapy and hypnotherapy was associated with decreased activation of the ventral (bottom-up) attentional network during bladder filling. This may be attributable to decreased afferent stimuli arising from the bladder in the pharmacotherapy group. In contrast, decreased ventral attentional network activation associated with hypnotherapy may be mediated by the counterbalancing effects of the dorsal (top-down) attentional network.
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Affiliation(s)
- Loren H Ketai
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico.
| | - Yuko M Komesu
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Ronald M Schrader
- University of New Mexico Clinical and Translational Science Center, Albuquerque, New Mexico
| | - Rebecca G Rogers
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico; University of Texas Dell Medical School, Austin, TX
| | - Robert E Sapien
- University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Poonai N, Powell EC, Schnadower D, Casper TC, Roskind CG, Olsen CS, Tarr P, Mahajan P, Rogers AJ, Schuh S, Hurley KF, Gouin S, Vance C, Farion KJ, Sapien RE, O’Connell KJ, Levine AC, Bhatt S, Freedman SB. Variables Associated With Intravenous Rehydration and Hospitalization in Children With Acute Gastroenteritis: A Secondary Analysis of 2 Randomized Clinical Trials. JAMA Netw Open 2021; 4:e216433. [PMID: 33871616 PMCID: PMC8056281 DOI: 10.1001/jamanetworkopen.2021.6433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
IMPORTANCE Despite guidelines endorsing oral rehydration therapy, intravenous fluids are commonly administered to children with acute gastroenteritis in high-income countries. OBJECTIVE To identify factors associated with intravenous fluid administration and hospitalization in children with acute gastroenteritis. DESIGN, SETTING, AND PARTICIPANTS This study is a planned secondary analysis of the Pediatric Emergency Research Canada (PERC) and Pediatric Emergency Care Applied Research Network (PECARN) probiotic trials. Participants include children aged 3 to 48 months with 3 or more watery stools in 24 hours between November 5, 2013, and April 7, 2017, for the PERC study and July 8, 2014, and June 23, 2017, for the PECARN Study. Children were from 16 pediatric emergency departments throughout Canada (6) and the US (10). Data were analyzed from November 2, 2018, to March 16, 2021. EXPOSURES Sex, age, preceding health care visit, distance between home and hospital, country (US vs Canada), frequency and duration of vomiting and diarrhea, presence of fever, Clinical Dehydration Scale score, oral ondansetron followed by oral rehydration therapy, and infectious agent. MAIN OUTCOMES AND MEASURES Intravenous fluid administration and hospitalization. RESULTS This secondary analysis of 2 randomized clinical trials included 1846 children (mean [SD] age, 19.1 [11.4] months; 1007 boys [54.6%]), of whom 534 of 1846 (28.9%) received oral ondansetron, 240 of 1846 (13.0%) received intravenous rehydration, and 67 of 1846 (3.6%) were hospitalized. The following were independently associated with intravenous rehydration: higher Clinical Dehydration Scale score (mild to moderate vs none, odds ratio [OR], 8.73; 95% CI, 5.81-13.13; and severe vs none, OR, 34.15; 95% CI, 13.45-86.73); country (US vs Canada, OR, 6.76; 95% CI, 3.15-14.49); prior health care visit with intravenous fluids (OR, 4.55; 95% CI, 1.32-15.72); and frequency of vomiting (per 5 episodes, OR, 1.66; 95% CI, 1.39-1.99). The following were independently associated with hospitalization: higher Clinical Dehydration Scale score (mild to moderate vs none, OR, 11.10; 95% CI, 5.05-24.38; and severe vs none, OR, 23.55; 95% CI, 7.09-78.25) and country (US vs Canada, OR, 3.37; 95% CI, 1.36-8.40). Oral ondansetron was associated with reduced odds of intravenous rehydration (OR, 0.21; 95% CI, 0.13-0.32) and hospitalization (OR, 0.44; 95% CI, 0.21-0.89). CONCLUSIONS AND RELEVANCE Intravenous rehydration and hospitalization were associated with clinical evidence of dehydration and lack of an oral ondansetron-supported oral rehydration period. Strategies focusing on oral ondansetron administration followed by oral rehydration therapy in children with dehydration may reduce the reliance on intravenous rehydration and hospitalization. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT01853124 (PERC) and NCT01773967 (PECARN).
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Affiliation(s)
- Naveen Poonai
- Department of Pediatrics, Schulich School of Medicine and Dentistry, London, Canada
- Department of Internal Medicine, Schulich School of Medicine and Dentistry, London, Canada
- Department of Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, London, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Canada
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | - Cindy G. Roskind
- Department of Emergency Medicine, Columbia University College of Physicians & Surgeons, New York, New York
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Philip Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Detroit
- Wayne State University, Detroit, Michigan
- Department of Emergency Medicine, University of Michigan, Ann Arbor
| | | | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, SickKids Research Institute, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Katrina F. Hurley
- Department of Emergency Medicine, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Serge Gouin
- Department of Pediatric Emergency Medicine, Université de Montréal, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Cheryl Vance
- Department of Pediatrics, University of California, Davis, School of Medicine, Sacramento
- Department of Emergency Medicine, University of California, Davis, School of Medicine, Sacramento
| | - Ken J. Farion
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Pediatric Emergency Department, Children’s Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children's National Hospital, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Adam C. Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence
| | - Seema Bhatt
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatric Medicine, Alberta Children’s Hospital, Alberta, Canada
- Section of Pediatric Emergency Medicine, Department of Emergency Medicine, Alberta Children’s Hospital, Alberta, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Schnadower D, Sapien RE, Casper TC, Vance C, Tarr PI, O'Connell KJ, Levine AC, Roskind CG, Rogers AJ, Bhatt SR, Mahajan P, Powell EC, Olsen CS, Gorelick MH, Dean JM, Freedman SB. Association between Age, Weight, and Dose and Clinical Response to Probiotics in Children with Acute Gastroenteritis. J Nutr 2021; 151:65-72. [PMID: 33274370 PMCID: PMC7779240 DOI: 10.1093/jn/nxaa313] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 06/25/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Gastroenteritis is a common and impactful disease in childhood. Probiotics are often used to treat acute gastroenteritis (AGE); however, in a large multicenter randomized controlled trial (RCT) in 971 children, Lactobacillus rhamnosus GG (LGG) was no better than placebo in improving patient outcomes. OBJECTIVES We sought to determine whether the effect of LGG is associated with age, weight z score and weight percentile adjusted for age and sex, or dose per kilogram administered. METHODS This was a preplanned secondary analysis of a multicenter double-blind RCT of LGG 1 × 1010 CFU twice daily for 5 d or placebo in children 3-48 mo of age with AGE. Our primary outcome was moderate to severe gastroenteritis. Secondary outcomes included diarrhea and vomiting frequency and duration, chronic diarrhea, and side effects. We used multivariable linear and nonlinear models testing for interaction effects to assess outcomes by age, weight z score and weight percentile adjusted for age and sex, and dose per kilogram of LGG received. RESULTS A total of 813 children (84%) were included in the analysis; 413 received placebo and 400 LGG. Baseline characteristics were similar between treatment groups. There were no differential interaction effects across ranges of age (P-interaction = 0.32), adjusted weight z score (P-interaction = 0.43), adjusted weight percentile (P-interaction = 0.45), or dose per kilogram of LGG received (P-interaction = 0.28) for the primary outcome. Whereas we found a statistical association favoring placebo at the extremes of adjusted weight z scores for the number of vomiting episodes (P-interaction = 0.02) and vomiting duration (P-interaction = 0.0475), there were no statistically significant differences in other secondary outcome measures (all P-interactions > 0.05). CONCLUSIONS LGG does not improve outcomes in children with AGE regardless of the age, adjusted weight z score, and adjusted weight percentile of participants, or the probiotic dose per kilogram received. These results further strengthen the conclusions of low risk of bias clinical trials which demonstrate that LGG provides no clinical benefit in children with AGE.This trial was registered at clinicaltrials.gov as NCT01773967.
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Affiliation(s)
- David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Karen J O'Connell
- Division of Emergency Medicine, Children's National Health System, Department of Pediatrics and Emergency Medicine, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Adam C Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence, RI, USA
| | - Cindy G Roskind
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Seema R Bhatt
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth C Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cody S Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Marc H Gorelick
- Central Administration, Children's Minnesota, Minneapolis, MN, USA
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Schnadower D, Roskind CG, VanBuren JM, Powell EC, Norris JG, Tarr PI, Sapien RE, O’Connell KJ, Chun TH, Rogers AJ, Bhatt SR, Mahajan P, Gorelick MH, Vance C, Dean JM, Freedman SB. Factors Associated With Nonadherence in an Emergency Department-based Multicenter Randomized Clinical Trial of a Probiotic in Children With Acute Gastroenteritis. J Pediatr Gastroenterol Nutr 2021; 72:24-28. [PMID: 32804911 PMCID: PMC10171126 DOI: 10.1097/mpg.0000000000002904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
ABSTRACT Nonadherence in clinical trials affects safety and efficacy determinations. Predictors of nonadherence in pediatric acute illness trials are unknown. We sought to examine predictors of nonadherence in a multicenter randomized trial of 971 children with acute gastroenteritis receiving a 5-day oral course of Lactobacillus rhamnosus GG or placebo. Adherence, defined as consuming all doses of the product, was reported by the parents and recorded during daily follow-up contacts. Of 943 patients with follow-up data, 766 (81.2%) were adherent. On multivariate analysis, older age (OR 1.19; 95% CI: 1.00-1.43), increased vomiting duration (OR 1.23; 95% CI: 1.05-1.45), higher dehydration score (OR 1.23, 95% CI: 1.07-1.42), and hospitalization following ED discharge (OR 4.16, 95% CI: 1.21--14.30) were factors associated with nonadherence; however, those with highest severity scores were more likely to adhere (OR 0.87, 95% CI: 0.80-0.95). These data may inform strategies and specific targets to maximize adherence in future pediatric trials.
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Affiliation(s)
- David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati OH
| | - Cindy G. Roskind
- Department of Emergency Medicine, Columbia University College of Physicians & Surgeons, New York, NY
| | - John M. VanBuren
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Elizabeth C. Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jesse G. Norris
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Phillip I. Tarr
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM
| | - Robert E. Sapien
- Division of Emergency Medicine, Children’s National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC
| | - Karen J. O’Connell
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children’s Hospital and Brown University, Providence, RI
| | - Thomas H. Chun
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor
| | - Alexander J. Rogers
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Seema R. Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics University of Cincinnati College of Medicine, Cincinnati OH
| | - Prashant Mahajan
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, CA
| | - J. Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Stephenson DD, Meier TB, Pabbathi Reddy S, Robertson-Benta CR, Hergert DC, Dodd AB, Shaff NA, Ling JM, Oglesbee SJ, Campbell RA, Phillips JP, Sapien RE, Mayer AR. Resting-State Power and Regional Connectivity After Pediatric Mild Traumatic Brain Injury. J Magn Reson Imaging 2020; 52:1701-1713. [PMID: 32592270 DOI: 10.1002/jmri.27249] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 05/20/2020] [Accepted: 05/21/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Physiological recovery from pediatric mild traumatic brain injury (pmTBI) as a function of age remains actively debated, with the majority of studies relying on subjective symptom report rather than objective markers of brain physiology. PURPOSE To examine potential abnormalities in fractional amplitude of low-frequency fluctuations (fALFF) or regional homogeniety (ReHo) during resting-state fMRI following pmTBI. STUDY TYPE Prospective cohort. POPULATION Consecutively recruited pmTBI (N = 105; 8-18 years old) and age- and sex-matched healthy controls (HC; N = 113). FIELD STRENGTH/SEQUENCE 3T multiecho gradient T1 -weighted and single-shot gradient-echo echo-planar imaging. ASSESSMENT All pmTBI participants were assessed 1 week and 4 months postinjury (HC assessed at equivalent timepoints after the first visit). Comprehensive demographic, clinical, and cognitive batteries were performed in addition to primary investigation of fALFF and ReHo. All pmTBI were classified as "persistent" or "recovered" based on both assessment periods. STATISTICAL TESTS Chi-square, nonparametric, and generalized linear models for demographic data. Generalized estimating equations for clinical and cognitive data. Voxelwise general linear models (AFNI's 3dMVM) for fALFF and ReHo assessment. RESULTS Evidence of recovery was observed for some, but not all, clinical and cognitive measures at 4 months postinjury. fALFF was increased in the left striatum for pmTBI relative to HC both at 1 week and 4 months postinjury; whereas no significant group differences (P > 0.001) were observed for ReHo. Age-at-injury did not moderate either resting-state metric across groups. In contrast to analyses of pmTBI as a whole, there were no significant (P > 0.001) differences in either fALFF or ReHo in patients with persistent postconcussive symptoms compared to recovered patients and controls at 4 months postinjury. DATA CONCLUSIONS Our findings suggest prolonged clinical recovery and alterations in the relative amplitude of resting-state fluctuations up to 4 months postinjury, but no clear relationship with age-at-injury or subjective symptom report. LEVEL OF EVIDENCE 1 TECHNICAL EFFICACY: 2 J. MAGN. RESON. IMAGING 2020;52:1701-1713.
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Affiliation(s)
| | - Timothy B Meier
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Department of Biomedical Engineering, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | | | | | - Andrew B Dodd
- The Mind Research Network/LBERI, Albuquerque, New Mexico, USA
| | | | - Josef M Ling
- The Mind Research Network/LBERI, Albuquerque, New Mexico, USA
| | - Scott J Oglesbee
- Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Richard A Campbell
- Departments of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, New Mexico, USA
| | - John P Phillips
- The Mind Research Network/LBERI, Albuquerque, New Mexico, USA
- Departments of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Robert E Sapien
- Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Andrew R Mayer
- The Mind Research Network/LBERI, Albuquerque, New Mexico, USA
- Departments of Psychiatry & Behavioral Sciences, University of New Mexico, Albuquerque, New Mexico, USA
- Departments of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
- Department of Psychology, University of New Mexico, Albuquerque, New Mexico, USA
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Komesu YM, Schrader RM, Rogers RG, Sapien RE, Mayer AR, Ketai LH. Hypnotherapy or medications: a randomized noninferiority trial in urgency urinary incontinent women. Am J Obstet Gynecol 2020; 222:159.e1-159.e16. [PMID: 31449805 PMCID: PMC6995419 DOI: 10.1016/j.ajog.2019.08.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2019] [Revised: 07/03/2019] [Accepted: 08/17/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Urgency urinary incontinence afflicts many adults, and most commonly affects women. Medications, a standard treatment, may be poorly tolerated, with poor adherence. This warrants investigation of alternative interventions. Mind-body therapies such as hypnotherapy may offer additional treatment options for individuals with urgency urinary incontinence. OBJECTIVE To evaluate hypnotherapy's efficacy compared to medications in treating women with urgency urinary incontinence. MATERIALS AND METHODS This investigator-masked, noninferiority trial compared hypnotherapy to medications at an academic center in the southwestern United States, and randomized women with non-neurogenic urgency urinary incontinence to weekly hypnotherapy sessions for 2 months (and continued self-hypnosis thereafter) or to medication and weekly counseling for 2 months (and medication alone thereafter). The primary outcome was the between-group comparison of percent change in urgency incontinence on a 3-day bladder diary at 2 months. Important secondary outcomes were between-group comparisons of percent change in urgency incontinence at 6 and 12 months. Outcomes were analyzed based on noninferiority margins of 5% for between group differences (P < 0.025) (that is, for between group difference in percentage change in urgency incontinence, if the lower bound of the 95% confidence interval was greater than -5%, noninferiority would be proved). RESULTS A total of 152 women were randomized to treatment between April 2013 and October 2016. Of these women, 142 (70 hypnotherapy, 72 medications) had 3-day diary information at 2 months and were included in the primary outcome analysis. Secondary outcomes were analyzed for women with diary data at the 6-month and then 12-month time points (138 women [67 hypnotherapy, 71 medications] at 6 months, 140 women [69 hypnotherapy, 71 medications] at 12 months. There were no differences between groups' urgency incontinence episodes at baseline: median (quartile 1, quartile 3) for hypnotherapy was 8 (4, 14) and medication was 7 (4, 11) (P = .165). For the primary outcome, although both interventions showed improvement, hypnotherapy did not prove noninferior to medication at 2 months. Hypnotherapy's median percent improvement was 73.0% (95% confidence interval, 60.0-88˖9%), whereas medication's improvement was 88.6% (95% confidence interval, 78.6-100.0%). The median difference in percent change between groups was 0% (95% confidence interval, -16.7% to 0.0%); because the lower margin of the confidence interval did not meet the predetermined noninferiority margin of greater than -5%, hypnotherapy did not prove noninferior to medication. In contrast, hypnotherapy was noninferior to medication for the secondary outcomes at 6 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 75.0-100%; medications, 83.3% improvement, 95% confidence interval, 64.7-100%; median difference in percent change between groups of 0%, 95% confidence interval, 0.0-6.7%) and 12 months (hypnotherapy, 85.7% improvement, 95% confidence interval, 66.7-94.4%; medications, 80% improvement, 95% confidence interval, 54.5-100%; median difference in percent change between groups of 0%, 95% confidence interval, -4.2% to -9.5%). CONCLUSION Both hypnotherapy and medications were associated with substantially improved urgency urinary incontinence at all follow-up. The study did not prove the noninferiority of hypnotherapy compared to medications at 2 months, the study's primary outcome. Hypnotherapy proved noninferior to medications at longer-term follow-up of 6 and 12 months. Hypnotherapy is a promising, alternative treatment for women with UUI.
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Affiliation(s)
- Yuko M Komesu
- University of New Mexico Health Sciences Center, Albuquerque, NM.
| | - Ronald M Schrader
- University of New Mexico Clinical and Translational Science Center, Albuquerque, NM
| | - Rebecca G Rogers
- University of New Mexico Health Sciences Center, Albuquerque, NM; University of Texas Dell Medical School, Austin, TX
| | - Robert E Sapien
- University of New Mexico Health Sciences Center, Albuquerque, NM
| | | | - Loren H Ketai
- University of New Mexico Health Sciences Center, Albuquerque, NM
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16
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Schnadower D, Tarr PI, Casper TC, Gorelick MH, Dean JM, O'Connell KJ, Mahajan P, Levine AC, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Olsen CS, Metheney M, Dickey VP, Hall-Moore C, Freedman SB. Lactobacillus rhamnosus GG versus Placebo for Acute Gastroenteritis in Children. N Engl J Med 2018; 379:2002-2014. [PMID: 30462938 PMCID: PMC6358014 DOI: 10.1056/nejmoa1802598] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute gastroenteritis develops in millions of children in the United States every year, and treatment with probiotics is common. However, data to support the use of probiotics in this population are limited. METHODS We conducted a prospective, randomized, double-blind trial involving children 3 months to 4 years of age with acute gastroenteritis who presented to one of 10 U.S. pediatric emergency departments. Participants received a 5-day course of Lactobacillus rhamnosus GG at a dose of 1×1010 colony-forming units twice daily or matching placebo. Follow-up surveys were conducted daily for 5 days and again 14 days after enrollment and 1 month after enrollment. The primary outcome was moderate-to-severe gastroenteritis, which was defined as an illness episode with a total score on the modified Vesikari scale of 9 or higher (scores range from 0 to 20, with higher scores indicating more severe disease), within 14 days after enrollment. Secondary outcomes included the duration and frequency of diarrhea and vomiting, the duration of day-care absenteeism, and the rate of household transmission (defined as the development of symptoms of gastroenteritis in previously asymptomatic household contacts). RESULTS Among the 971 participants, 943 (97.1%) completed the trial. The median age was 1.4 years (interquartile range, 0.9 to 2.3), and 513 participants (52.9%) were male. The modified Vesikari scale score for the 14-day period after enrollment was 9 or higher in 55 of 468 participants (11.8%) in the L. rhamnosus GG group and in 60 of 475 participants (12.6%) in the placebo group (relative risk, 0.96; 95% confidence interval, 0.68 to 1.35; P=0.83). There were no significant differences between the L. rhamnosus GG group and the placebo group in the duration of diarrhea (median, 49.7 hours in the L. rhamnosus GG group and 50.9 hours in the placebo group; P=0.26), duration of vomiting (median, 0 hours in both groups; P=0.17), or day-care absenteeism (median, 2 days in both groups; P=0.67) or in the rate of household transmission (10.6% and 14.1% in the two groups, respectively; P=0.16). CONCLUSIONS Among preschool children with acute gastroenteritis, those who received a 5-day course of L. rhamnosus GG did not have better outcomes than those who received placebo. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; ClinicalTrials.gov number, NCT01773967 .).
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Affiliation(s)
- David Schnadower
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Phillip I Tarr
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - T Charles Casper
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Marc H Gorelick
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - J Michael Dean
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Karen J O'Connell
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Prashant Mahajan
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Adam C Levine
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Seema R Bhatt
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cindy G Roskind
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Elizabeth C Powell
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Alexander J Rogers
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cheryl Vance
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Robert E Sapien
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Cody S Olsen
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Melissa Metheney
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Viani P Dickey
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Carla Hall-Moore
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
| | - Stephen B Freedman
- From the Divisions of Pediatric Emergency Medicine (D.S., V.P.D.) and Gastroenterology, Hepatology, and Nutrition (P.I.T., C.H.-M.), Department of Pediatrics, Washington University School of Medicine, St. Louis; the Department of Pediatrics, University of Utah, Salt Lake City (T.C.C., J.M.D., C.S.O., M.M.); Central Administration, Department of Pediatrics, University of Minnesota School of Medicine, Minneapolis (M.H.G.); the Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, George Washington School of Medicine and Health Sciences, Washington, DC (K.J.O.); the Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Wayne State University, Detroit (P.M.); the Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor (P.M., A.J.R.); the Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence (A.C.L.); the Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati (D.S., S.R.B.); the Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York (C.G.R.); the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago (E.C.P.); the Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento (C.V.); the Department of Emergency Medicine, University of New Mexico, Albuquerque (R.E.S.); and the Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada (S.B.F.)
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Schnadower D, Tarr PI, Charles CT, Gorelick MH, Dean MJ, O’Connell KJ, Mahajan P, Chun TH, Bhatt SR, Roskind CG, Powell EC, Rogers AJ, Vance C, Sapien RE, Gao F, Freedman SB. Randomised controlled trial of Lactobacillus rhamnosus (LGG) versus placebo in children presenting to the emergency department with acute gastroenteritis: the PECARN probiotic study protocol. BMJ Open 2017; 7:e018115. [PMID: 28947466 PMCID: PMC5623493 DOI: 10.1136/bmjopen-2017-018115] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Acute gastroenteritis (AGE) is a common and burdensome condition that affects millions of children worldwide each year. Currently available strategies are limited to symptomatic management, treatment and prevention of dehydration and infection control; no disease-modifying interventions exist. Probiotics, defined as live microorganisms beneficial to the host, have shown promise in improving AGE outcomes, but existing studies have sufficient limitations such that the use of probiotics cannot currently be recommended with confidence. Here we present the methods of a large, rigorous, randomised, double-blind placebo-controlled study to assess the effectiveness and side effect profile of Lactobacillus rhamnosus GG (LGG) (ATCC 53103) in children with AGE. METHODS AND ANALYSIS The study is being conducted in 10 US paediatric emergency departments (EDs) within the federally funded Pediatric Emergency Care Applied Research Network, in accordance with current SPIRIT and CONSORT statement recommendations. We will randomise 970 children presenting to participating EDs with AGE to either 5 days of treatment with LGG (1010colony-forming unit twice a day) or placebo between July 2014 to December 2017. The main outcome is the occurrence of moderate-to-severe disease over time, as defined by the Modified Vesikari Scale. We also record adverse events and side effects related to the intervention. We will conduct intention-to-treat analyses and use an enrichment design to restore the statistical power in case the presence of a subpopulation with a substantially low treatment effect is identified. ETHICS AND DISSEMINATION Institutional review board approval has been obtained at all sites, and data and material use agreements have been established between the participating sites. The results of the trial will be published in peer-reviewed journals. A deidentified public data set will be made available after the completion of all study procedures. TRIAL REGISTRATION NUMBER NCT01773967.
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Affiliation(s)
- David Schnadower
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Phillip I Tarr
- Division of Gastroenterology and Nutrition, Department of Pediatrics, Washington University, School of Medicine, St. Louis, Missouri, USA
| | - Casper T Charles
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Marc H Gorelick
- Central Administration, Children’s Hospital Minnesota, Minneapolis, Minnesota, USA
| | - Michael J Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Karen J O’Connell
- Division of Emergency Medicine, Children’s National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Prashant Mahajan
- Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan Wayne State University, Detroit, Michigan, USA
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas H Chun
- Department of Emergency Medicine and Pediatrics Providence, Hasbro Children’s Hospital and Brown University, Providence, Rhode Island, USA
| | - Seema R Bhatt
- Division of Emergency Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Cindy G Roskind
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians & Surgeons, New York, New York, USA
| | - Elizabeth C Powell
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, University of California, Davis, School of Medicine, Sacramento, California, USA
| | - Robert E Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Feng Gao
- Department of Surgery, Division of Public Health Sciences, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Elgie R, Sapien RE, Fullerton-Gleason L. The New Mexico School Nurse and Emergency Medical Services Emergency Preparedness Course: Program Description and Evaluation. J Sch Nurs 2016; 21:218-23. [PMID: 16048366 DOI: 10.1177/10598405050210040601] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Illness and injuries are common among students and school staff. Therefore, school nurses must be prepared. In this study, a 16-hour scenario-based emergency preparedness course for school nurses was evaluated for its effectiveness. Effectiveness was measured by (a) traditional methods (written exams and confidence surveys) and (b) skills and performance evaluations in simulated emergencies called On-site Mock Emergency Scenarios. School nurses who completed the emergency preparedness course showed significant improvement in knowledge, confidence, and On-site Mock Emergency Scenarios scores that measured each nurse’s ability to apply knowledge in simulated emergencies.
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Affiliation(s)
- Robert Elgie
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Komesu YM, Rogers RG, Sapien RE, Schrader RM, Simmerman-Sierra T, Mayer AR, Ketai LH. Methodology for a trial of brain-centered versus anticholinergic therapy in women with urgency urinary incontinence. Int Urogynecol J 2016; 28:865-874. [PMID: 27752750 DOI: 10.1007/s00192-016-3169-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 09/21/2016] [Indexed: 12/17/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We describe the rationale and methodology for a study comparing mind-body treatment and pharmacotherapy in women with urgency urinary incontinence (UUI). To explore brain associations in UUI, a subset of patients will also undergo functional magnetic resonance imaging (fMRI). We hypothesize that hypnotherapy, a mind-body intervention, will be at least as effective as pharmacotherapy in treating UUI. We also hypothesize that fMRI findings will change following treatment, with changes potentially differing between groups. METHODS We describe the development and design challenges of a study comparing the efficacy of hypnotherapy and conventional pharmacotherapy in the treatment of UUI. The study randomizes women to either of these treatments, and outcome measures include bladder diaries and validated questionnaires. Sample size estimates, based on a noninferiority test (alpha = 0.025, beta = 0.20), after considering dropout subjects and subjects lost to follow-up, indicated that approximately 150 woman would be required to test the hypothesis that hypnotherapy is not inferior to pharmacotherapy within a 5 % noninferiority margin. The study will also evaluate fMRI changes in a subset of participants before and after therapy. Challenges included designing a study with a mind-body therapy and a comparison treatment equally acceptable to participants, standardizing the interventions, and confronting the reality that trials are time-consuming for participants who have to make appropriate accommodations in their schedule. RESULTS Study enrollment began in March 2013 and is ongoing. CONCLUSIONS We describe the design of a randomized controlled trial comparing mind-body therapy and pharmacotherapy in the treatment of UUI and the challenges encountered in its implementation.
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Affiliation(s)
- Yuko M Komesu
- Health Sciences Center, University of New Mexico, Albuquerque, NM, USA.
- Health Sciences Center Department of Obstetrics and Gynecology, University of New Mexico, MSC10-5580, Albuquerque, NM, 87131-0001, USA.
- University of New Mexico, Albuquerque, NM, 87131-0001, USA.
| | - Rebecca G Rogers
- Health Sciences Center, University of New Mexico, Albuquerque, NM, USA
| | - Robert E Sapien
- Health Sciences Center, University of New Mexico, Albuquerque, NM, USA
| | - Ronald M Schrader
- Clinical and Translational Science Center, University of New Mexico, Albuquerque, NM, USA
| | | | | | - Loren H Ketai
- Health Sciences Center, University of New Mexico, Albuquerque, NM, USA
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Horeczko T, Marcin JP, Kahn JM, Sapien RE. Urban and Rural Patterns in Emergent Pediatric Transfer: A Call for Regionalization. J Rural Health 2013; 30:252-8. [DOI: 10.1111/jrh.12051] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy Horeczko
- Department of Emergency Medicine; University of California; Davis, Sacramento California
- Department of Emergency Medicine; Harbor-UCLA Medical Center; Torrance California
| | - James P. Marcin
- Department of Pediatrics, Division of Critical Care; University of California; Davis, Sacramento California
| | - Jeremy M. Kahn
- Departments of Critical Care Medicine and Health Policy & Management; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Robert E. Sapien
- Department of Emergency Medicine; University of New Mexico; Albuquerque New Mexico
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Sapien RE, Gleason-Fullerton L, Berger K. Lethargic children: a term misused in pediatric emergency medicine. Am J Emerg Med 2006; 24:394-5. [PMID: 16635736 DOI: 10.1016/j.ajem.2005.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2005] [Revised: 11/18/2005] [Accepted: 11/18/2005] [Indexed: 11/24/2022] Open
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Abstract
OBJECTIVE To demonstrate that school teachers can be taught to recognize respiratory distress in asthmatic children. METHODOLOGY Forty-five school teachers received a one-hour educational session on childhood asthma. Each education session consisted of two portions, video footage of asthmatic children exhibiting respiratory distress and didactic. Pre- and posttests on general asthma knowledge, signs of respiratory distress on video footage and comfort level with asthma knowledge and medications were administered. RESULTS General asthma knowledge median scores increased significantly, pre = 60% correct, post = 70% (p < 0.0001). The ability to visually recognize respiratory distress also significantly improved (pre-median = 66.7% correct, post = 88.9% [p < 0.0001]). Teachers' comfort level with asthma knowledge and medications improved. CONCLUSIONS Using video footage, school teachers can be taught to visually recognize respiratory distress in asthmatic children. Improvement in visual recognition of respiratory distress was greater than improvement in didactic asthma information.
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Affiliation(s)
- Robert E Sapien
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico 87131-0001, USA.
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Sapien RE, Fullerton-Gleason L, Allen N. Teaching School Teachers to Recognize Respiratory Distress in Asthmatic Children. J Asthma 2004. [DOI: 10.1081/jas-12199900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico Healtlh Sciences Center, Albuquerque, New Mexico, USA
| | - L. Fullerton-Gleason
- Department of Emergency Medicine, University of New Mexico Healtlh Sciences Center, Albuquerque, New Mexico, USA
| | - N. Allen
- Department of Emergency Medicine, University of New Mexico Healtlh Sciences Center, Albuquerque, New Mexico, USA
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Affiliation(s)
- Ricci S Pardini
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
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Abstract
OBJECTIVE To determine preschool children's response to a commercial back-up warning alarm in a mock setting of an automobile backing up. SETTING Preschool parking lot in Albuquerque, New Mexico, USA. METHODS With subjects acting as their own controls, 33 preschoolers were asked to walk behind a stationary vehicle twice. The first time, the control, no warning sound was emitted from the vehicle. The second time, the vehicle was placed in reverse gear triggering an alarm. Children's responses were recorded by a hidden video camera. Avoidance behavior by the child was considered a positive response. Location and distance to where the response occurred was measured. RESULTS Thirty three children, 38-61 months, were studied. None responded to the alarm with avoidance behavior but 18 looked toward the vehicle or hesitated in their gait. CONCLUSION Although over half of the children acknowledged the warning alarm, the device did not elicit avoidance behavior. Mere acknowledgment of the warning device would not prevent injury.
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Affiliation(s)
- R E Sapien
- Department of Emergency Medicine, University of New Mexico Health Science Center, Albuquerque, New Mexico 87131, USA.
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Abstract
OBJECTIVE To study emergency preparedness in public schools in a rural state. METHOD Questionnaires were mailed to school nurses registered with the State Department of Education. Data collected included school nurse and staff training, school location, emergency equipment available, and Emergency Medical Service (EMS) access. RESULTS Seventy-two percent of the surveys were returned after one or two mailings. They report little emergency training for both school nurses and school staff. Emergency equipment available varies widely: oxygen 20%, artificial airways 30%, cervical collars 22%, splints 69%. Equipment was more likely to be available in communities with populations of less than 200,000. Sixty-seven percent of schools activate EMS for a student and 37% for an adult annually. Eighty-four percent of schools have a less than 10-minute EMS response time. CONCLUSIONS EMS activation to schools is a common occurrence. Schools are ill prepared to care for this acuity of student or staff as assessed by equipment and emergency training. Schools in smaller communities, however, are better prepared for emergencies.
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Affiliation(s)
- R E Sapien
- University of New Mexico Health Sciences Center, Department of Emergency Medicine, Albuquerque, New Mexico 87131-5246, USA.
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Affiliation(s)
- R E Sapien
- University of New Mexico Health Sciences Center, Department of Emergency Medicine, Albuquerque 87131, USA.
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Abstract
Questionnaires given to school nurses were used to collect data regarding emergency asthma equipment and plans. Sixty-three percent reported <10 asthmatic visits per month, 25% reported 10-50, and 12% reported >50. Only 20% of school nurses reported that 75%-100% of asthmatic students had an emergency plan, and 24% did not know if asthmatic students had a plan. Only half of the nurses had input into the plan. Equipment varied: 16% had oxygen, 45% had peak flow meters, 0% had MDIs, and 20% had nebulizers available. Many asthmatic students lack emergency plans, and many school nurses are not involved in the plans.
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Affiliation(s)
- R E Sapien
- University of New Mexico Health Science Center, Department of Emergency Medicine, Albuquerque 87131, USA.
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Abstract
STUDY OBJECTIVE To determine whether implementation of a set of standardized pediatric telephone triage protocols results in consistent triage dispositions when applied by different operators. METHODS A descriptive study with interrater comparisons was performed. Telephone interviews simulated the setting of a triage station in a university hospital-based pediatric emergency department. A mock parent presented 15 standardized respiratory cases in random order to 12 pediatric ED nurses. Nurses assigned patients' complaints to severity categories using 9 respiratory complaint protocols extracted from a commercially available pediatric telephone triage tool. Protocol selection and severity endpoints were recorded. Interobserver agreement among nurses was analyzed by the kappa statistic. Comparisons of operator characteristics and triage results were carried out by ANOVA. RESULTS Interrater agreement in triage disposition among nurses was poor (kappa,.11; 95% confidence interval,.02 to.20). Protocol selection varied; the group used a mean of 3 different disposition-generating protocols per case. Disposition also varied, with up to 4 different severity endpoints per protocol in a given case. A post-hoc comparison of the mean disposition severity between nurses did not reach significance at an adjusted level (P =.04). Fifty-eight percent of the nurses felt confined by the protocols, and 42% admitted to at least 1 intentional deviation from them. CONCLUSION It may not simply be assumed that the use of protocols will standardize care. This is particularly important in the case of triage, with current trends toward medical decisionmaking by less skilled providers with diminishing patient contact. Although triage protocols may be useful to guide clinical thinking, their consistency must be validated before they may be safely disseminated for general use.
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Affiliation(s)
- D A Wachter
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA
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Abstract
OBJECTIVE To compare pediatric ambulance patients transported for chief complaints of suicide, assault, alcohol, and drug intoxication (SAAD) with pediatric patients transported for all other chief complaints. METHODS An out-of-hospital database for the primary transporting service in an urban area was analyzed for patients 0-20 years of age from 1992 to 1995. Chief complaints by age, gender, and billing status were analyzed. RESULTS There were 17,722 transports. The SAAD group comprised 14.9% of all transports (suicide attempt 1.6%, assault 5.9%, alcohol intoxication 3.2%, and drug abuse 4.2%). The proportion of transports due to SAAD increased with age: 0-11-year-olds (4.2%); 11-16-year-olds (17.5%); and 17-20-year-olds (20.3%) (p = 0.0001). Genders were equally represented in the overall group, while males comprised 52.6% of the SAAD transports (p = 0.032). In the SAAD group, the majority of transports for assaults (55.9%) and alcohol (58.8%) involved males, while females were the majority in transports for suicide (52.3%) and drug abuse (66%) (p = 0.0001). Reimbursement sources differed, with those in the SAAD group less likely to be reimbursed by private or public (Medicaid, government) insurance (p < 0.0001) compared with the overall group. CONCLUSIONS A substantial proportion of pediatric emergency medical services transports are for high-risk conditions. This patient population differs from the overall group by age distribution and reimbursement source.
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Affiliation(s)
- R E Sapien
- Department of Emergency Medicine, University of New Mexico School of Medicine, Albuquerque 87131-5246, USA
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Abstract
OBJECTIVE To compare pre-EMS intervention (bystander intervention) with EMS intervention (performed by fire department/EMS personnel) in the management of airway foreign bodies in children. METHODS First-responding paramedic run reports for 1994 in the metropolitan area (city and county fire departments) pertaining to acute foreign body airway obstruction in children (aged 0-15 years) were reviewed. Data regarding age, gender, type of foreign body, method by which the airway was cleared, and mode of transportation were extracted. RESULTS There were 103 runs with an age distribution as follows: 0-11 months 39.8%; 1-5 years 50.5%; and >6 years 9.7%. Fifty-eight (56.3%) involved males and 45 (43.7%) involved females. Eighty-five percent of the airways were cleared before EMS arrival. Thirty-eight percent were self-cleared by the child. The chance of airway clearance before EMS arrival increased with increasing age: 78% of the children aged 0-11 months, 88.5% of the children 1-5 years of age, and 100% of the children aged 6 years or older had their airways cleared before EMS arrival. Forty-four percent of the children were not transported, and 27% were transported by private vehicle. Coins and food were the two most common foreign bodies. CONCLUSION The majority of airway foreign bodies were cleared before EMS arrival, especially in older children. This supports CPR training of new parents and the general population and has training implications for the EMS provider in managing the pediatric airway.
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Affiliation(s)
- J J Andazola
- University of New Mexico, School of Medicine, Albuquerque, USA
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Abstract
Many asthmatic children require assistance by emergency medical services (EMS) secondary to an acute asthma episode. What medication interventions are being utilized by EMS when responding to an asthma call for a child, and how does EMS management compare to home management given before ambulance arrival (pre EMS)? Sixty-one ambulance reports pertaining to acute asthma episodes in children aged 1 month to 15 years were collected and analyzed. There was no significant difference between likelihood to receive a beta 2-agonist nebulizer treatment pre-EMS arrival or by EMS. Oxygen was the most common EMS intervention.
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Affiliation(s)
- R E Sapien
- Department of Emergency Medicine, University of New Mexico, School of Medicine, Albuquerque, USA
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Graham SD, Olson LM, Sapien RE, Tandberg D, Sklar DP. Adequacy of EMS data collection during pediatric cardiac arrest: are EMTs getting the whole story? PREHOSP EMERG CARE 1997; 1:28-31. [PMID: 9709317 DOI: 10.1080/10903129708958781] [Citation(s) in RCA: 7] [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: 02/08/2023]
Abstract
OBJECTIVE To compare the initial emergency medical services (EMS) prehospital assessment of medical and traumatic cardiopulmonary arrest in the pediatric patient with that of the Office of the Medical Investigator (OMI) and assess differences and implications for EMS training and prevention. DESIGN Retrospective review of ambulance run forms with the OMI autopsy confirmations. SETTING An urban EMS system and the state Office of the Medical Investigator. PARTICIPANTS Patients 15 years of age or less who were treated by prehospital personnel from November 1, 1990, to October 31, 1991, for a medical or traumatic arrest. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Ambulance runs were reported for 2,586 pediatric patients. Of these, 42 (1.6%) had suffered arrests, with 32 (76%) medical arrests and ten (24%) traumatic arrests. Children 1 year of age or less accounted for 75% of the medical arrests, while children more than 1 year of age accounted for 80% of the traumatic arrests (p = 0.003). Overall mortality was 81%. When EMS prehospital assessments of medical and traumatic arrests were compared with autopsy reports, there was good agreement for sudden infant death syndrome (SIDS) (kappa = 0.70), but poor agreement for child abuse (kappa = 0.37). CONCLUSION The authors found good agreement between EMS prehospital assessments and autopsy diagnoses for identifying pediatric SIDS, but child abuse was not well identified prior to autopsy.
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Affiliation(s)
- S D Graham
- University of New Mexico, Department of Emergency Medicine, UNM School of Medicine, Ambulatory Care Center, Albuquerque 87131-5246, USA
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Abstract
To compare and contrast retrospective versus concurrent quality of care review processes in a Level I Trauma Center, we conducted a retrospective chart review of all pediatric trauma admissions in 1990 (n = 113) and compared it to the concurrent trauma quality assurance program for the same time period. Twenty-four percent (24%) of the patients reviewed in the retrospective study were identified by filters and reviewed through the concurrent process. In both the retrospective and concurrent review process problems in medical care problems, documentation, social and preventive elements of the case, and overall assessment of the patients' care were described. Overall, we found less than 50% agreement between the two reviews. The retrospective review identified medical care issues in 64% of cases, compared with a 44% error rate noted in the concurrent review (P < 0.07). Reviewers were more likely to note the absence of appropriate documentation, and overall assessment of the patients' care in the retrospective process (P < 0.0001). The retrospective review also highlighted issues related to the prevention of the injury and the patients' social situation, which were not considered by the concurrent review. Overall, we found the concurrent review appropriate for case by case medical management, while the retrospective review was relevant to a systems approach to the care of the injured child. To obtain a complete picture of the care of injured children, we recommend 1) a portion of charts be reviewed retrospectively in addition to ongoing concurrent review; or 2) the concurrent review add filters that are specific to pediatric issues and overall system issues.
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Affiliation(s)
- R E Sapien
- University of New Mexico, Department of Emergency Medicine, Albuquerque 87131, USA
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Vogel KG, Kendall VF, Sapien RE. Glycosaminoglycan synthesis and composition in human fibroblasts during in vitro cellular aging (IMR-90). J Cell Physiol 1981; 107:271-81. [PMID: 7251685 DOI: 10.1002/jcp.1041070214] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
The synthesis and turnover of sulfate-labeled glycosaminoglycans(35S-GAGs) has been investigated in diploid human embryo fibroblasts during in vitro cellular aging. With progressive subcultivation, there was a decreased incorporation of Na2(35)SO4 into 35S-GAGs released to the medium, but not into those accumulated at the cell surface. The composition of 35S-GAGs found in extracellular medium, cell surface (removable by gentle proteolysis), and intracellular compartments of the culture after 48-hr labeling did not change significantly with progressive subcultivation. Pulse-labeled 35S-GAGs moved from intracellular to surface and extracellular compartments more slowly in late-passage cultures. Addition of 1 mM beta-xyloside to both early- and late-passage cultures produced a ten-fold enhancement of extracellular 35S-GAG production without a concomitant increase in surface-associated 35S-GAG. We interpret the data of this study to mean that secreted and cell-surface glycosaminoglycans represent different pools and that cellular aging has its effect primarily upon the secreted pool of glycosaminoglycans. Late-passage fibroblasts demonstrate marked decreases in proliferation, culture density, fibronectin matrix, and gap-junction formation. Our results suggest that glycosaminoglycan synthesis and composition are not intimately related to these parameters.
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