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Florin TA, Ramilo O, Banks RK, Schnadower D, Quayle KS, Powell EC, Pickett ML, Nigrovic LE, Mistry R, Leetch AN, Hickey RW, Glissmeyer EW, Dayan PS, Cruz AT, Cohen DM, Bogie A, Balamuth F, Atabaki SM, VanBuren JM, Mahajan P, Kuppermann N. Radiographic pneumonia in young febrile infants presenting to the emergency department: secondary analysis of a prospective cohort study. Emerg Med J 2023; 41:13-19. [PMID: 37770118 PMCID: PMC10841819 DOI: 10.1136/emermed-2023-213089] [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: 02/02/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The lack of evidence-based criteria to guide chest radiograph (CXR) use in young febrile infants results in variation in its use with resultant suboptimal quality of care. We sought to describe the features associated with radiographic pneumonias in young febrile infants. STUDY DESIGN Secondary analysis of a prospective cohort study in 18 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from 2016 to 2019. Febrile (≥38°C) infants aged ≤60 days who received CXRs were included. CXR reports were categorised as 'no', 'possible' or 'definite' pneumonia. We compared demographics, clinical signs and laboratory tests among infants with and without pneumonias. RESULTS Of 2612 infants, 568 (21.7%) had CXRs performed; 19 (3.3%) had definite and 34 (6%) had possible pneumonias. Patients with definite (4/19, 21.1%) or possible (11/34, 32.4%) pneumonias more frequently presented with respiratory distress compared with those without (77/515, 15.0%) pneumonias (adjusted OR 2.17; 95% CI 1.04 to 4.51). There were no differences in temperature or HR in infants with and without radiographic pneumonias. The median serum procalcitonin (PCT) level was higher in the definite (0.7 ng/mL (IQR 0.1, 1.5)) vs no pneumonia (0.1 ng/mL (IQR 0.1, 0.3)) groups, as was the median absolute neutrophil count (ANC) (definite, 5.8 K/mcL (IQR 3.9, 6.9) vs no pneumonia, 3.1 K/mcL (IQR 1.9, 5.3)). No infants with pneumonia had bacteraemia. Viral detection was frequent (no pneumonia (309/422, 73.2%), definite pneumonia (11/16, 68.8%), possible pneumonia (25/29, 86.2%)). Respiratory syncytial virus was the predominant pathogen in the pneumonia groups and rhinovirus in infants without pneumonias. CONCLUSIONS Radiographic pneumonias were uncommon in febrile infants. Viral detection was common. Pneumonia was associated with respiratory distress, but few other factors. Although ANC and PCT levels were elevated in infants with definite pneumonias, further work is necessary to evaluate the role of blood biomarkers in infant pneumonias.
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Affiliation(s)
- Todd A Florin
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Octavio Ramilo
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Russell K Banks
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - David Schnadower
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Kimberly S Quayle
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Elizabeth C Powell
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Michelle L Pickett
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lise E Nigrovic
- Department of Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rakesh Mistry
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Aaron N Leetch
- Departments of Emergency Medicine and Pediatrics, University of Arizona Medical Center-Diamond Children's, Tucson, Arizona, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Eric W Glissmeyer
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Peter S Dayan
- Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Andrea T Cruz
- Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Daniel M Cohen
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Amanda Bogie
- Department of Pediatrics, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma, USA
| | - Fran Balamuth
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Shireen M Atabaki
- Emergency Medicine, Children's National Health System, Washington, District of Columbia, USA
- Department of Pediatrics, Children's National Health System, Washington, District of Columbia, USA
| | - John M VanBuren
- Department of Pediatrics, University of Utah Medical Center, Salt Lake City, Utah, USA
| | - Prashant Mahajan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, Sacramento, California, USA
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Kontos AP, Eagle SR, Braithwaite R, Preszler J, Manderino L, Turner RL, Jennings S, Trbovich A, Hickey RW, Collins MW, McCrea M, Nelson LD, Root J, Thomas DG. The Effects of Rest on Concussion Symptom Resolution and Recovery Time: A Meta-analytic Review and Subgroup Analysis of 4329 Patients. Am J Sports Med 2023; 51:3893-3903. [PMID: 36847271 DOI: 10.1177/03635465221150214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
BACKGROUND Numerous individual studies suggest that rest may have a negative effect on outcomes following concussion. PURPOSE To perform a systematic meta-analysis of the effects of prescribed rest compared with active interventions after concussion. STUDY DESIGN Meta-analysis; Level of evidence, 4. METHODS A meta-analysis (using the Hedges g) of randomized controlled trials and cohort studies was conducted to evaluate the effects of prescribed rest on symptoms and recovery time after concussion. Subgroup analyses were performed for methodological, study, and sample characteristics. Data sources were obtained from systematic search of key terms using Ovid Medline, Embase, Cochrane Database of Systematic Reviews, APA PsycINFO, Web of Science, SPORTDiscus, and ProQuest dissertations and theses through May 28, 2021. Eligible studies were those that (1) assessed concussion or mild traumatic brain injury; (2) included symptoms or days to recovery for ≥2 time points; (3) included 2 groups with 1 group assigned to rest; and (4) were written in the English language. RESULTS In total, 19 studies involving 4239 participants met criteria. Prescribed rest had a significant negative effect on symptoms (k = 15; g = -0.27; SE = 0.11; 95% CI, -0.48 to -0.05; P = .04) but not on recovery time (k = 8; g = -0.16; SE = 0.21; 95% CI, -0.57 to 0.26; P = .03). Subgroup analyses suggested that studies with shorter duration (<28 days) (g = -0.46; k = 5), studies involving youth (g = -0.33; k = 12), and studies focused on sport-related concussion (g = -0.38; k = 8) reported higher effect sizes. CONCLUSION The findings support a small negative effect for prescribed rest on symptoms after concussion. Younger age and sport-related mechanisms of injury were associated with a greater negative effect size. However, the lack of support for an effect for recovery time and the relatively small overall numbers of eligible studies highlight ongoing concerns regarding the quantity and rigor of clinical trials in concussion. REGISTRATION CRD42021253060 (PROSPERO).
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Affiliation(s)
- Anthony P Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Shawn R Eagle
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rock Braithwaite
- Department of Kinesiology and Recreation Administration, Cal Poly Humboldt, Arcata, California, USA
| | - Jonathan Preszler
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Lisa Manderino
- UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Rose L Turner
- Health Science Library System, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Alicia Trbovich
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Children's Hospital of Pittsburgh Division of Emergency Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael W Collins
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; UPMC Sports Medicine Concussion Program, Pittsburgh, Pennsylvania, USA
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lindsay D Nelson
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jeremy Root
- Pediatric Emergency Medicine, George Washington School of Medicine, Washington, DC, USA; Children's National Health System, Fairfax, Virginia, USA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA; Pediatric Emergency Medicine, Children's Wisconsin, Wauwatosa, Wisconsin, USA)
- Investigation performed at University of Pittsburgh Medical Center Sports Concussion Program and University of Pittsburgh Department of Orthopaedic Surgery, Pittsburgh, Pennsylvania, USA
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Peterson Lu E, Bowen J, Foglia M, Ribar E, Mack M, Sondhi E, Hickey RW. Etiologies of Poor Weight Gain and Ultimate Diagnosis in Children Admitted for Growth Faltering. Hosp Pediatr 2023; 13:394-402. [PMID: 37082920 DOI: 10.1542/hpeds.2022-007038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND AND OBJECTIVES Growth faltering (GF) (previously failure to thrive) is a common reason for hospital admission, but there is little data on whether diagnoses made during initial admission remain accurate in follow-up. We sought to characterize infants admitted for isolated GF and identify diagnoses at discharge and ultimate diagnoses determined over 2 years of follow-up, to determine how diagnoses changed. We also sought to identify patient factors on admission associated with ultimate diagnosis. METHODS We conducted a retrospective study of children aged 2 weeks to 2 years with index admissions for GF from 2013 to 2017. We reviewed clinical data and documentation to determine discharge and ultimate diagnosis, and identify factors associated with ultimate diagnosis. RESULTS Of 497 patients, 292 (59%) had insufficient intake, 103 (20%) had organic disease including 36 genetic disorders, 52 (11%) had mechanical feeding difficulties, and 50 (10%) had mixed or unknown diagnoses 2 years after admission. Over 90% of cases of insufficient intake were diagnosed during admission. Sixty-five percent of organic diseases, and only 39% of genetic disorders, were diagnosed during admission. Patient factors associated with genetic disorders included previous NICU stay, low birth weight, dysphagia, hypotonia, and dysmorphisms. CONCLUSIONS Insufficient intake remains the most common diagnosis, and this diagnosis was accurately made during admission. Organic disease, especially genetic disease, was often not diagnosed during admission. Better tools are needed to identify patients with organic disease. We identified patient factors on admission associated with ultimate diagnosis, which could be used to prioritize evaluation and expedite follow-up.
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Affiliation(s)
- Elise Peterson Lu
- Paul C. Gaffney Division of Pediatric Hospital Medicine
- Departments of Pediatrics
| | - James Bowen
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Matthew Foglia
- Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ellen Ribar
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Molly Mack
- Divisions of Pediatric Hematology/Oncology
| | - Esha Sondhi
- Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert W Hickey
- Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Departments of Pediatrics
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Rees CA, Brousseau DC, Ahmad FA, Bennett J, Bhatt S, Bogie A, Brown KM, Casper TC, Chapman LL, Chumpitazi CE, Cohen DM, Dampier C, Ellison AM, Grasemann H, Hatabah D, Hickey RW, Hsu LL, Bakshi N, Leibovich S, Patil P, Powell EC, Richards R, Sarnaik S, Weiner DL, Morris CR. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. Am J Hematol 2023; 98:620-627. [PMID: 36606705 PMCID: PMC10023395 DOI: 10.1002/ajh.26837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 12/23/2022] [Accepted: 01/01/2023] [Indexed: 01/07/2023]
Abstract
Children with sickle cell disease (SCD) commonly experience vaso-occlusive pain episodes (VOE) due to sickling of erythrocytes, which often requires care in the emergency department. Our objective was to assess the use and impact of intranasal fentanyl for the treatment of children with SCD-VOE on discharge from the emergency department in a multicenter study. We conducted a cross-sectional study at 20 academic pediatric emergency departments in the United States and Canada. We used logistic regression to test bivariable and multivariable associations between the outcome of discharge from the emergency department and candidate variables theoretically associated with discharge. The study included 400 patients; 215 (54%) were female. The median age was 14.6 (interquartile range 9.8, 17.6) years. Nineteen percent (n = 75) received intranasal fentanyl in the emergency department. Children who received intranasal fentanyl had nearly nine-fold greater adjusted odds of discharge from the emergency department compared to those who did not (adjusted odds ratio 8.99, 95% CI 2.81-30.56, p < .001). The rapid onset of action and ease of delivery without intravenous access offered by intranasal fentanyl make it a feasible initial parenteral analgesic in the treatment of children with SCD presenting with VOE in the acute-care setting. Further study is needed to determine potential causality of the association between intranasal fentanyl and discharge from the emergency department observed in this multicenter study.
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Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - David C. Brousseau
- Section of Pediatric Emergency Medicine, Medical College of Wisconsin and the Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Fahd A. Ahmad
- Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Seema Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda Bogie
- Univesrsity of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | | | - Laura L. Chapman
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Corrie E. Chumpitazi
- Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Carlton Dampier
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Dunia Hatabah
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Robert W. Hickey
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Lewis L. Hsu
- University of Illinois at Chicago, Chicago, Illinois
| | - Nitya Bakshi
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Sara Leibovich
- UCSF-Benioff Children’s Hospital at Oakland, Oakland, California
| | | | - Elizabeth C. Powell
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rachel Richards
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Debra L. Weiner
- Division of Pediatric Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Claudia R. Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
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Brent DA, Horowitz LM, Grupp-Phelan J, Bridge JA, Gibbons R, Chernick LS, Rea M, Cwik MF, Shenoi RP, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange MD, Rogers A, Cohen DM, Keller A, Hickey RW, Page K, Casper TC, King CA. Prediction of Suicide Attempts and Suicide-Related Events Among Adolescents Seen in Emergency Departments. JAMA Netw Open 2023; 6:e2255986. [PMID: 36790810 PMCID: PMC9932829 DOI: 10.1001/jamanetworkopen.2022.55986] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
Abstract
IMPORTANCE Screening adolescents in emergency departments (EDs) for suicidal risk is a recommended strategy for suicide prevention. Comparing screening measures on predictive validity could guide ED clinicians in choosing a screening tool. OBJECTIVE To compare the Ask Suicide-Screening Questions (ASQ) instrument with the Computerized Adaptive Screen for Suicidal Youth (CASSY) instrument for the prediction of suicidal behavior among adolescents seen in EDs, across demographic and clinical strata. DESIGN, SETTING, AND PARTICIPANTS The Emergency Department Study for Teens at Risk for Suicide is a prospective, random-series, multicenter cohort study that recruited adolescents, oversampled for those with psychiatric symptoms, who presented to the ED from July 24, 2017, through October 29, 2018, with a 3-month follow-up to assess the occurrence of suicidal behavior. The study included 14 pediatric ED members of the Pediatric Emergency Care Applied Research Network and 1 Indian Health Service ED. Statistical analysis was performed from May 2021 through January 2023. MAIN OUTCOMES AND MEASURES This study used a prediction model to assess outcomes. The primary outcome was suicide attempt (SA), and the secondary outcome was suicide-related visits to the ED or hospital within 3 months of baseline; both were assessed by an interviewer blinded to baseline information. The ASQ is a 4-item questionnaire that surveys suicidal ideation and lifetime SAs. A positive response or nonresponse on any item indicates suicidal risk. The CASSY is a computerized adaptive screening tool that always includes 3 ASQ items and a mean of 8 additional items. The CASSY's continuous outcome is the predicted probability of an SA. RESULTS Of 6513 adolescents available, 4050 were enrolled, 3965 completed baseline assessments, and 2740 (1705 girls [62.2%]; mean [SD] age at enrollment, 15.0 [1.7] years; 469 Black participants [17.1%], 678 Hispanic participants [24.7%], and 1618 White participants [59.1%]) completed both screenings and follow-ups. The ASQ and the CASSY showed a similar sensitivity (0.951 [95% CI, 0.918-0.984] vs 0.945 [95% CI, 0.910-0.980]), specificity (0.588 [95% CI, 0.569-0.607] vs 0.643 [95% CI, 0.625-0.662]), positive predictive value (0.127 [95% CI, 0.109-0.146] vs 0.144 [95% CI, 0.123-0.165]), and negative predictive value (both 0.995 [95% CI, 0.991-0.998], respectively). Area under the receiver operating characteristic curve findings were similar among patients with physical symptoms (ASQ, 0.88 [95% CI, 0.81-0.95] vs CASSY, 0.94 [95% CI, 0.91-0.96]). Among patients with psychiatric symptoms, the CASSY performed better than the ASQ (0.72 [95% CI, 0.68-0.77] vs 0.57 [95% CI, 0.55-0.59], respectively). CONCLUSIONS AND RELEVANCE This study suggests that both the ASQ and the CASSY are appropriate for universal screening of patients in pediatric EDs. For the small subset of patients with psychiatric symptoms, the CASSY shows greater predictive validity.
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Affiliation(s)
- David A. Brent
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- UPMC Western Psychiatric Hospital, Pittsburgh, Pennsylvania
| | - Lisa M. Horowitz
- Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | | | - Jeffrey A. Bridge
- The Abigail Wexner Research Institute at Nationwide Children’s Hospital, Columbus, Ohio
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus
| | - Robert Gibbons
- Department of Medicine, The University of Chicago, Chicago, Illinois
- Department of Public Health Sciences (Biostatistics), The University of Chicago, Chicago, Illinois
- Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois
- Department of Comparative Human Development, The University of Chicago, Chicago, Illinois
| | - Lauren S. Chernick
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Columbia University Irving Medical Center, New York, New York
| | - Margaret Rea
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, California
| | - Mary F. Cwik
- Department of International Health, Social and Behavioral Interventions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Rohit P. Shenoi
- Division of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joel A. Fein
- Center for Violence Prevention, Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia
| | - E. Melinda Mahabee-Gittens
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Shilpa J. Patel
- Division of Pediatric Emergency Medicine, Children’s National Hospital, Washington, DC
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC
- Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Rakesh D. Mistry
- Department of Pediatrics, University of Colorado School of Medicine, Aurora
| | - Susan Duffy
- Hasbro Children’s Hospital, Department of Pediatrics, Alpert Medical School at Brown University, Providence, Rhode Island
| | | | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Pediatrics, University of Michigan, Ann Arbor
| | - Daniel M. Cohen
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Allison Keller
- Department of Pediatric Emergency Medicine, University of Utah and Primary Children’s Hospital, Salt Lake City
| | - Robert W. Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kent Page
- Department of Pediatrics, University of Utah, Salt Lake City
| | | | - Cheryl A. King
- Department of Psychiatry, Michigan Medicine, Ann Arbor
- Injury Prevention Center, The University of Michigan, Ann Arbor
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Schmucker KA, Zuckerbraun NS, Vitale MA, Hickey RW, Callaway CW, Pitetti RD, Saladino RA, Manole MD. Increased Fellow Scholarly Publication Rate After Implementation of a Comprehensive Research Curriculum and Milestone-Based Research Timeline for Pediatric Emergency Medicine Fellows. Pediatr Emerg Care 2023; 39:e11-e14. [PMID: 35477926 DOI: 10.1097/pec.0000000000002715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Pediatric subspecialty fellows are required to complete a scholarly product during training; however, many do not bring the work to publication. To amplify our fellows' publication success, our pediatric emergency medicine fellowship program implemented a comprehensive research curriculum and established a milestone-based research timeline for each component of a project. Our objective was to assess whether these interventions increased the publication rate and enhanced the graduated fellows' perceived ability to perform independent research. METHODS Our study was conducted at a tertiary children's hospital affiliated with an academic university, enrolling 3 fellows each year in its pediatric emergency medicine program. A comprehensive research curriculum and a milestone-based research timeline were implemented in 2011. We analyzed the publication rate of our graduating fellows before (2004-2011) and after (2012-2016) our intervention. In addition, in 2017 we surveyed our previous fellows who graduated from 2004 to 2016 and analyzed factors favoring manuscript publication and confidence with various research skills. RESULTS During the study period, 38 trainees completed the fellowship program. Publication rate increased from 26% ± 17% to 87% ± 30 % ( P < 0.05). When scoring the importance of various factors, fellows most valued mentorship (5 ± 0 vs 4.3 ± 1.0, P < 0.05, postintervention vs preintervention) for the completion of the fellowship study and manuscript. Fellows after the intervention reported greater confidence in performing an analysis of variance (89% vs 36%, odds ratio, 6.3; 95% confidence interval, 1.4-150.1). CONCLUSIONS Implementation of a comprehensive research curriculum and a milestone-based research timeline was associated with an increase in the publication rate within 3 years of graduation of our pediatric emergency medicine fellows. After implementation, fellows reported an increased importance of mentorship and greater confidence in performing an analysis of variance. We provide a comprehensive curriculum and a research timeline that may serve as a model for other fellowship programs.
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Affiliation(s)
- Kyle A Schmucker
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Noel S Zuckerbraun
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Melissa A Vitale
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Robert W Hickey
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Clifton W Callaway
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Raymond D Pitetti
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Richard A Saladino
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
| | - Mionora D Manole
- From the Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh
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Thomas DG, Erpenbach H, Hickey RW, Waltzman D, Haarbauer-Krupa J, Nelson LD, Patterson CG, McCrea MA, Collins MW, Kontos AP. Implementation of active injury management (AIM) in youth with acute concussion: A randomized controlled trial. Contemp Clin Trials 2022; 123:106965. [PMID: 36252936 PMCID: PMC10924688 DOI: 10.1016/j.cct.2022.106965] [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: 06/08/2022] [Revised: 09/10/2022] [Accepted: 10/11/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Nearly 2 million youth seek acute medical care following concussion in the U.S. each year. Current standard of care recommends rest for the first 48 h after a concussion. However, research suggests that prolonged rest may lengthen recovery time especially for patients with certain risk profiles. Research indicates that physical activity and behavioral management interventions (sleep, stress management) may enhance recovery. To date, there is limited empirical evidence to inform acute (<72 h) concussion recommendations for physical activity and behavioral management in adolescents. OBJECTIVE To determine the effectiveness of physical activity and behavioral management for acute concussion in adolescents and young adults, and to evaluate the role of patient characteristics on treatment response. METHODS This multicenter prospective randomized controlled trial will determine which combination of physical activity and behavioral management is most effective for patients 11-24 years old who present to the emergency department or concussion clinic within 72 h of injury. Participants are randomized into: 1) rest, 2) physical activity, 3) mobile health application (mHealth) behavioral management, or 4) physical activity and mHealth app conditions. Assessments at enrollment, 3-5 days, 14 days, 1 month, and 2 months include: concussion symptoms, balance, vestibular-ocular and cognitive assessments, quality of life, and recovery time. Somatic symptoms and other risk factors are evaluated at enrollment. Compliance with treatment and symptoms are assessed daily using actigraph and daily self-report. The primary study outcome is symptoms at 14 days. CONCLUSION Prescribed physical activity and behavioral management may improve outcomes in youth following acute concussion.
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Affiliation(s)
- D G Thomas
- Medical College of Wisconsin, Department of Pediatrics, United States of America.
| | - H Erpenbach
- Medical College of Wisconsin, Department of Pediatrics, United States of America
| | - R W Hickey
- University of Pittsburgh, Department of Pediatrics, United States of America
| | - D Waltzman
- Centers for Disease Control and Prevention, United States of America
| | - J Haarbauer-Krupa
- Centers for Disease Control and Prevention, United States of America
| | - L D Nelson
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - C G Patterson
- University of Pittsburgh, Department of Physical Therapy, United States of America
| | - M A McCrea
- Medical College of Wisconsin, Department of Neurosurgery, United States of America
| | - M W Collins
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
| | - A P Kontos
- University of Pittsburgh, Department of Orthopedic Surgery, United States of America
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8
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Rees CA, Brousseau DC, Ahmad FA, Bennett J, Bhatt S, Bogie A, Brown KM, Casper TC, Chapman LL, Chumpitazi CE, Cohen DM, Dampier C, Ellison AM, Grasemann H, Hickey RW, Hsu LL, Lane PA, Bakshi N, Leibovich S, Patil P, Powell EC, Richards R, Sarnaik S, Weiner DL, Morris CR. Adherence to NHLBI guidelines for the emergent management of vaso-occlusive episodes in children with sickle cell disease: A multicenter perspective. Am J Hematol 2022; 97:E412-E415. [PMID: 36054566 PMCID: PMC9561082 DOI: 10.1002/ajh.26696] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 01/28/2023]
Affiliation(s)
- Chris A. Rees
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - David C. Brousseau
- Children’s Research Institute of the Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Fahd A. Ahmad
- Division of Emergency Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | | | - Seema Bhatt
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda Bogie
- Univesrsity of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | | | | | - Laura L. Chapman
- Alpert Medical School, Brown University, Providence, Rhode Island
| | - Corrie E. Chumpitazi
- Division of Pediatric Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Carlton Dampier
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Robert W. Hickey
- Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Lewis L. Hsu
- University of Illinois at Chicago, Chicago, Illinois
| | - Peter A. Lane
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Nitya Bakshi
- Division of Pediatric Hematology/Oncology/BMT, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
- Aflac Cancer and Blood Disorders Center, Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Sara Leibovich
- UCSF-Benioff Children’s Hospital at Oakland, Oakland, California
| | | | - Elizabeth C. Powell
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rachel Richards
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | | | - Debra L. Weiner
- Division of Pediatric Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Claudia R. Morris
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Children’s Healthcare of Atlanta, Atlanta, Georgia
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9
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Amin AB, Lash TL, Tate JE, Waller LA, Wikswo ME, Parashar UD, Stewart LS, Chappell JD, Halasa NB, Williams JV, Michaels MG, Hickey RW, Klein EJ, Englund JA, Weinberg GA, Szilagyi PG, Staat MA, McNeal MM, Boom JA, Sahni LC, Selvarangan R, Harrison CJ, Moffatt ME, Schuster JE, Pahud BA, Weddle GM, Azimi PH, Johnston SH, Payne DC, Bowen MD, Lopman BA. Understanding Variation in Rotavirus Vaccine Effectiveness Estimates in the United States: The Role of Rotavirus Activity and Diagnostic Misclassification. Epidemiology 2022; 33:660-668. [PMID: 35583516 PMCID: PMC10100583 DOI: 10.1097/ede.0000000000001501] [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: 11/25/2022]
Abstract
BACKGROUND Estimates of rotavirus vaccine effectiveness (VE) in the United States appear higher in years with more rotavirus activity. We hypothesized rotavirus VE is constant over time but appears to vary as a function of temporal variation in local rotavirus cases and/or misclassified diagnoses. METHODS We analyzed 6 years of data from eight US surveillance sites on 8- to 59-month olds with acute gastroenteritis symptoms. Children's stool samples were tested via enzyme immunoassay (EIA); rotavirus-positive results were confirmed with molecular testing at the US Centers for Disease Control and Prevention. We defined rotavirus gastroenteritis cases by either positive on-site EIA results alone or positive EIA with Centers for Disease Control and Prevention confirmation. For each case definition, we estimated VE against any rotavirus gastroenteritis, moderate-to-severe disease, and hospitalization using two mixed-effect regression models: the first including year plus a year-vaccination interaction, and the second including the annual percent of rotavirus-positive tests plus a percent positive-vaccination interaction. We used multiple overimputation to bias-adjust for misclassification of cases defined by positive EIA alone. RESULTS Estimates of annual rotavirus VE against all outcomes fluctuated temporally, particularly when we defined cases by on-site EIA alone and used a year-vaccination interaction. Use of confirmatory testing to define cases reduced, but did not eliminate, fluctuations. Temporal fluctuations in VE estimates further attenuated when we used a percent positive-vaccination interaction. Fluctuations persisted until bias-adjustment for diagnostic misclassification. CONCLUSIONS Both controlling for time-varying rotavirus activity and bias-adjusting for diagnostic misclassification are critical for estimating the most valid annual rotavirus VE.
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Affiliation(s)
- Avnika B. Amin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Jacqueline E. Tate
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Lance A. Waller
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Mary E. Wikswo
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Umesh D. Parashar
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Laura S. Stewart
- Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - James D. Chappell
- Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - Natasha B. Halasa
- Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University Medical Center, Nashville, TN
| | - John V. Williams
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Marian G. Michaels
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert W. Hickey
- Department of Pediatrics, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Eileen J. Klein
- Department of Pediatrics, Seattle Children’s Research Institute, Seattle Children’s Hospital and the University of Washington, Seattle, WA
| | - Janet A. Englund
- Department of Pediatrics, Seattle Children’s Research Institute, Seattle Children’s Hospital and the University of Washington, Seattle, WA
| | | | - Peter G. Szilagyi
- University of Rochester School of Medicine and Dentistry, Rochester, NY
- University of California at Los Angeles, Los Angeles, CA
| | - Mary Allen Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Monica M. McNeal
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Julie A. Boom
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Texas Children’s Hospital, Houston, TX
| | - Leila C. Sahni
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Texas Children’s Hospital, Houston, TX
| | | | | | | | | | | | | | - Parvin H. Azimi
- University of California—San Francisco Benioff Children’s Hospital Oakland, Oakland, CA
| | - Samantha H. Johnston
- University of California—San Francisco Benioff Children’s Hospital Oakland, Oakland, CA
- Pediatric Infectious Diseases, Stanford University School of Medicine, Stanford, CA
| | - Daniel C. Payne
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Michael D. Bowen
- Division of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA
| | - Benjamin A. Lopman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
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10
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Stem CT, Ramgopal S, Hickey RW, Manole MD, Balzer JR. Effect of ketamine on transcranial Doppler Gosling pulsatility index in children undergoing procedural sedation: A pilot study. J Am Coll Emerg Physicians Open 2022; 3:e12760. [PMID: 35865130 PMCID: PMC9292470 DOI: 10.1002/emp2.12760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 05/02/2022] [Accepted: 05/16/2022] [Indexed: 11/11/2022] Open
Abstract
Objectives There has been controversy over whether ketamine affects intracranial pressure (ICP) in children. Transcranial Doppler ultrasound (TCD) is a validated technique used to assess ICP changes noninvasively. Gosling pulsatility index (PI) directly correlates with ICP changes. The objective of this study was to quantify PI changes as a surrogate marker for ICP changes in previously healthy children receiving intravenous ketamine for procedural sedation. Methods We performed a prospective, observational study of patients 5–18 years old who underwent sedation with intravenous ketamine as monotherapy. ICP changes were assessed by surrogate PI at baseline, immediately after ketamine administration, and every 5 minutes until completion of the procedure. The primary outcome measure was PI change after ketamine administration compared to baseline (denoted ΔPI). Results We enrolled 15 participants. Mean age was 9.9 ± 3.4 years. Most participants underwent sedation for fracture reduction (87%). Mean initial ketamine dose was 1.4 ± 0.3 mg/kg. PI decreased at all time points after ketamine administration. Mean ΔPI at sedation onset was –0.23 (95% confidence interval [CI] = –0.30 to –0.15), at 5 minutes was –0.23 (95% CI = –0.28 to –0.18), at 10 minutes was –0.14 (95% CI = –0.21 to –0.08), at 15 minutes was –0.18 (95% CI = –0.25 to –0.12), and at 20 minutes was –0.19 (95% CI = –0.26 to –0.12). Using a clinically relevant threshold of ΔPI set at +1 (+8 cm H2O), no elevation in ICP, based on the PI surrogate marker, was demonstrated with 95% confidence at all time points after ketamine administration. Conclusions Ketamine did not significantly increase PI, which was used as a surrogate marker for ICP in this sample of previously healthy children. This pilot study demonstrates a model for evaluating ICP changes noninvasively in the emergency department.
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Affiliation(s)
- Christopher T. Stem
- Division of Pediatric Emergency Medicine Department of Pediatrics Medical University of South Carolina Charleston South Carolina USA
- Division of Emergency Medicine Department of Pediatrics UPMC Children's Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Sriram Ramgopal
- Division of Emergency Medicine Department of Pediatrics Ann & Robert H. Lurie Children's Hospital of Chicago Northwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Robert W. Hickey
- Division of Emergency Medicine Department of Pediatrics UPMC Children's Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Mioara D. Manole
- Division of Emergency Medicine Department of Pediatrics UPMC Children's Hospital of Pittsburgh Pittsburgh Pennsylvania USA
| | - Jeffrey R. Balzer
- Department of Neurological Surgery University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
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11
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Ko ER, Henao R, Frankey K, Petzold EA, Isner PD, Jaehne AK, Allen N, Gardner-Gray J, Hurst G, Pflaum-Carlson J, Jayaprakash N, Rivers EP, Wang H, Ugalde I, Amanullah S, Mercurio L, Chun TH, May L, Hickey RW, Lazarus JE, Gunaratne SH, Pallin DJ, Jambaulikar G, Huckins DS, Ampofo K, Jhaveri R, Jiang Y, Komarow L, Evans SR, Ginsburg GS, Tillekeratne LG, McClain MT, Burke TW, Woods CW, Tsalik EL. Prospective Validation of a Rapid Host Gene Expression Test to Discriminate Bacterial From Viral Respiratory Infection. JAMA Netw Open 2022; 5:e227299. [PMID: 35420659 PMCID: PMC9011121 DOI: 10.1001/jamanetworkopen.2022.7299] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [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] [Received: 11/03/2021] [Accepted: 02/24/2022] [Indexed: 12/24/2022] Open
Abstract
Importance Bacterial and viral causes of acute respiratory illness (ARI) are difficult to clinically distinguish, resulting in the inappropriate use of antibacterial therapy. The use of a host gene expression-based test that is able to discriminate bacterial from viral infection in less than 1 hour may improve care and antimicrobial stewardship. Objective To validate the host response bacterial/viral (HR-B/V) test and assess its ability to accurately differentiate bacterial from viral infection among patients with ARI. Design, Setting, and Participants This prospective multicenter diagnostic study enrolled 755 children and adults with febrile ARI of 7 or fewer days' duration from 10 US emergency departments. Participants were enrolled from October 3, 2014, to September 1, 2019, followed by additional enrollment of patients with COVID-19 from March 20 to December 3, 2020. Clinical adjudication of enrolled participants identified 616 individuals as having bacterial or viral infection. The primary analysis cohort included 334 participants with high-confidence reference adjudications (based on adjudicator concordance and the presence of an identified pathogen confirmed by microbiological testing). A secondary analysis of the entire cohort of 616 participants included cases with low-confidence reference adjudications (based on adjudicator discordance or the absence of an identified pathogen in microbiological testing). Thirty-three participants with COVID-19 were included post hoc. Interventions The HR-B/V test quantified the expression of 45 host messenger RNAs in approximately 45 minutes to derive a probability of bacterial infection. Main Outcomes and Measures Performance characteristics for the HR-B/V test compared with clinical adjudication were reported as either bacterial or viral infection or categorized into 4 likelihood groups (viral very likely [probability score <0.19], viral likely [probability score of 0.19-0.40], bacterial likely [probability score of 0.41-0.73], and bacterial very likely [probability score >0.73]) and compared with procalcitonin measurement. Results Among 755 enrolled participants, the median age was 26 years (IQR, 16-52 years); 360 participants (47.7%) were female, and 395 (52.3%) were male. A total of 13 participants (1.7%) were American Indian, 13 (1.7%) were Asian, 368 (48.7%) were Black, 131 (17.4%) were Hispanic, 3 (0.4%) were Native Hawaiian or Pacific Islander, 297 (39.3%) were White, and 60 (7.9%) were of unspecified race and/or ethnicity. In the primary analysis involving 334 participants, the HR-B/V test had sensitivity of 89.8% (95% CI, 77.8%-96.2%), specificity of 82.1% (95% CI, 77.4%-86.6%), and a negative predictive value (NPV) of 97.9% (95% CI, 95.3%-99.1%) for bacterial infection. In comparison, the sensitivity of procalcitonin measurement was 28.6% (95% CI, 16.2%-40.9%; P < .001), the specificity was 87.0% (95% CI, 82.7%-90.7%; P = .006), and the NPV was 87.6% (95% CI, 85.5%-89.5%; P < .001). When stratified into likelihood groups, the HR-B/V test had an NPV of 98.9% (95% CI, 96.1%-100%) for bacterial infection in the viral very likely group and a positive predictive value of 63.4% (95% CI, 47.2%-77.9%) for bacterial infection in the bacterial very likely group. The HR-B/V test correctly identified 30 of 33 participants (90.9%) with acute COVID-19 as having a viral infection. Conclusions and Relevance In this study, the HR-B/V test accurately discriminated bacterial from viral infection among patients with febrile ARI and was superior to procalcitonin measurement. The findings suggest that an accurate point-of-need host response test with high NPV may offer an opportunity to improve antibiotic stewardship and patient outcomes.
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Affiliation(s)
- Emily R. Ko
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Hospital Medicine, Division of General Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Department of Biostatistics and Informatics, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Katherine Frankey
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Elizabeth A. Petzold
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Pamela D. Isner
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Anja K. Jaehne
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Nakia Allen
- Department of Pediatrics, Henry Ford Hospital System, Detroit, Michigan
| | - Jayna Gardner-Gray
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Gina Hurst
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Jacqueline Pflaum-Carlson
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Namita Jayaprakash
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital System, Detroit, Michigan
| | - Emanuel P. Rivers
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, Michigan
- Department of Surgery, Henry Ford Hospital System, Detroit, Michigan
| | - Henry Wang
- McGovern Medical University of Texas Health, Houston
- Department of Emergency Medicine, The Ohio State University, Columbus
| | - Irma Ugalde
- McGovern Medical University of Texas Health, Houston
| | - Siraj Amanullah
- Department of Emergency Medicine, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
| | - Laura Mercurio
- Department of Emergency Medicine, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
| | - Thomas H. Chun
- Department of Emergency Medicine, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
- Department of Pediatrics, Alpert Medical School of Brown University, Hasbro Children’s Hospital, Providence, Rhode Island
| | - Larissa May
- Department of Emergency Medicine, University of California, Davis
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob E. Lazarus
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Shauna H. Gunaratne
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, New York
| | - Daniel J. Pallin
- Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - David S. Huckins
- Department of Emergency Medicine, Newton-Wellesley Hospital, Boston, Massachusetts
| | - Krow Ampofo
- Department of Pediatrics, University of Utah, Salt Lake City
| | - Ravi Jhaveri
- Department of Pediatrics, University of North Carolina at Chapel Hill
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yunyun Jiang
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Lauren Komarow
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Scott R. Evans
- The Biostatistics Center, George Washington University, Rockville, Maryland
| | - Geoffrey S. Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - L. Gayani Tillekeratne
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Micah T. McClain
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Thomas W. Burke
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Christopher W. Woods
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Medical Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
| | - Ephraim L. Tsalik
- Center for Applied Genomics and Precision Medicine, Duke University School of Medicine, Durham, North Carolina
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Emergency Medicine Service, Durham Veterans Affairs Health Care System, Durham, North Carolina
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12
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Shah MM, Perez A, Lively JY, Avadhanula V, Boom JA, Chappell J, Englund JA, Fregoe W, Halasa NB, Harrison CJ, Hickey RW, Klein EJ, McNeal MM, Michaels MG, Moffatt ME, Otten C, Sahni LC, Schlaudecker E, Schuster JE, Selvarangan R, Staat MA, Stewart LS, Weinberg GA, Williams JV, Ng TFF, Routh JA, Gerber SI, McMorrow ML, Rha B, Midgley CM. Enterovirus D68-Associated Acute Respiratory Illness ─ New Vaccine Surveillance Network, United States, July-November 2018-2020. MMWR Morb Mortal Wkly Rep 2021; 70:1623-1628. [PMID: 34818320 PMCID: PMC8612514 DOI: 10.15585/mmwr.mm7047a1] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Enterovirus D68 (EV-D68) is associated with a broad spectrum of illnesses, including mild to severe acute respiratory illness (ARI) and acute flaccid myelitis (AFM). Enteroviruses, including EV-D68, are typically detected in the United States during late summer through fall, with year-to-year fluctuations. Before 2014, EV-D68 was infrequently reported to CDC (1). However, numbers of EV-D68 detection have increased in recent years, with a biennial pattern observed during 2014-2018 in the United States, after the expansion of surveillance and wider availability of molecular testing. In 2014, a national outbreak of EV-D68 was detected (2). EV-D68 was also reported in 2016 via local (3) and passive national (4) surveillance. EV-D68 detections were limited in 2017, but substantial circulation was observed in 2018 (5). To assess recent levels of circulation, EV-D68 detections in respiratory specimens collected from patients aged <18 years* with ARI evaluated in emergency departments (EDs) or admitted to one of seven U.S. medical centers† within the New Vaccine Surveillance Network (NVSN) were summarized. This report provides a provisional description of EV-D68 detections during July-November in 2018, 2019 and 2020, and describes the demographic and clinical characteristics of these patients. In 2018, a total of 382 EV-D68 detections in respiratory specimens obtained from patients aged <18 years with ARI were reported by NVSN; the number decreased to six detections in 2019 and 30 in 2020. Among patients aged <18 years with EV-D68 in 2020, 22 (73%) were non-Hispanic Black (Black) persons. EV-D68 detections in 2020 were lower than anticipated based on the biennial circulation pattern observed since 2014. The circulation of EV-D68 in 2020 might have been limited by widespread COVID-19 mitigation measures; how these changes in behavior might influence the timing and levels of circulation in future years is unknown. Ongoing monitoring of EV-D68 detections is warranted for preparedness for EV-D68-associated ARI and AFM.
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13
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Zhou AZ, Marin JR, Hickey RW, Lam SK, Ramgopal S. Serious diagnoses at revisits in children discharged from the emergency department with back pain. Acad Emerg Med 2021; 28:1299-1307. [PMID: 34245643 DOI: 10.1111/acem.14336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Back pain is often benign but can be a harbinger for serious pathology. Little is known about the outcome in children with back pain but no serious diagnoses detected at the initial visit. We sought to estimate the rate of serious diagnoses at revisits among children initially discharged from the emergency department (ED) with back pain. METHODS We performed a multicenter retrospective cohort study of patients from 45 pediatric hospitals in the Pediatric Health Information System database from October 1, 2015, to March 31, 2019. We included patients discharged from the ED with a principal diagnosis of back pain and excluded patients with trauma and concurrent or previously known serious diagnoses. We identified the rates and types of serious diagnoses made within 30 days of the index visit. We examined the rates of diagnostic tests at the index visit in patients with and without serious diagnoses. RESULTS Of the 25,130 patients with back pain, 88 (0.4%, 95% confidence interval = 0.3% to 0.4%) had serious pathology diagnosed within 30 days. The most common diagnoses were anatomic (40%) and nonneurologic (39%) categories such as vertebral fracture and nephrolithiasis; infectious (19%) and neoplastic etiologies (3%) were less common. Diagnoses requiring acute interventions such as cauda equina syndrome (n = 2) and intraspinal abscess (n = 3) were rare. Patients with serious diagnoses at revisits underwent more blood tests and back ultrasound at the index visit compared to patients without serious diagnoses. CONCLUSIONS In pediatric patients discharged from the ED with a diagnosis of back pain and no serious or trauma diagnoses, there is a low rate of serious pathology on revisits. Of the serious diagnoses identified, high-acuity diseases were rare. For the subset of patients with clinical suspicion for serious pathology but none identified at the index visit, this represents an opportunity for further research to optimize their management.
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Affiliation(s)
- Amy Z. Zhou
- Division of Emergency Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Jennifer R. Marin
- Division of Pediatric Emergency Medicine Department of Pediatrics UPMC Children’s Hospital of PittsburghUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
- Department of Emergency Medicine University of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine Department of Pediatrics UPMC Children’s Hospital of PittsburghUniversity of Pittsburgh School of Medicine Pittsburgh Pennsylvania USA
| | - Sandi K. Lam
- Department of Neurosurgery Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
| | - Sriram Ramgopal
- Division of Emergency Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern University Feinberg School of Medicine Chicago Illinois USA
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14
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Abstract
OBJECTIVES Serious bacterial infections (SBIs) in young infants can present with fever or hypothermia. There are substantial data on fever as a presentation for SBI that help to inform the clinical approach. In contrast, data on hypothermia are lacking, thus leaving clinicians without guidance. We aimed to describe the workup and findings, specifically the occurrence, of SBIs in infants younger than 60 days of life with hypothermia. METHODS We reviewed the medical records of infants younger than 60 days of life with rectal temperature of less than 36.5°C upon arrival to a children's hospital emergency department between January 2013 and December 2014. Comparisons were made between those who were found to have an SBI and those without. Serious bacterial infection was defined as bacteremia, bacterial meningitis, pneumonia, or urinary tract infection (UTI). RESULTS From the 414 patients identified, 104 (25%) underwent a sepsis evaluation of blood, urine, and/or cerebrospinal fluid culture. Serious bacterial infections were identified in 9 patients: 4 with UTI, 1 with pneumonia, 2 with bacteremia, 1 with pneumonia and UTI, and 1 with meningitis and bacteremia. Compared with patients with negative cultures, patients with SBI were older and had elevated absolute band counts and elevated immature-to-total neutrophil ratio. CONCLUSIONS Approximately a quarter of infants younger than 60 days with hypothermia were evaluated for SBI. Serious bacterial infection was identified in 9% of evaluated infants (2% of all hypothermic infants). Hypothermia can be a presenting sign of SBI.
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Affiliation(s)
- Michelle C Perry
- Children’s Hospital of Pittsburgh of UPMC, Department of Pediatrics
| | - Susan K Yaeger
- Lehigh Valley Health Network, Department of Emergency Medicine
| | - Katie Noorbakhsh
- Children’s Hospital of Pittsburgh of UPMC, Department of Pediatrics
| | - Andrea T Cruz
- Baylor College of Medicine, Department of Pediatrics
| | - Robert W Hickey
- Children’s Hospital of Pittsburgh of UPMC, Department of Pediatrics
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Rosenthal ES, Elm JJ, Ingles J, Rogers AJ, Terndrup TE, Holsti M, Thomas DG, Babcock L, Okada PJ, Lipsky RH, Miller JB, Hickey RW, Barra ME, Bleck TP, Cloyd JC, Silbergleit R, Lowenstein DH, Coles LD, Kapur J, Shinnar S, Chamberlain JM. Early Neurologic Recovery, Practice Pattern Variation, and the Risk of Endotracheal Intubation Following Established Status Epilepticus. Neurology 2021; 96:e2372-e2386. [PMID: 34032604 PMCID: PMC8166444 DOI: 10.1212/wnl.0000000000011879] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 02/08/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To quantify the association between early neurologic recovery, practice pattern variation, and endotracheal intubation during established status epilepticus, we performed a secondary analysis within the cohort of patients enrolled in the Established Status Epilepticus Treatment Trial (ESETT). METHODS We evaluated factors associated with the endpoint of endotracheal intubation occurring within 120 minutes of ESETT study drug initiation. We defined a blocked, stepwise multivariate regression, examining 4 phases during status epilepticus management: (1) baseline characteristics, (2) acute treatment, (3) 20-minute neurologic recovery, and (4) 60-minute recovery, including seizure cessation and improving responsiveness. RESULTS Of 478 patients, 117 (24.5%) were intubated within 120 minutes. Among high-enrolling sites, intubation rates ranged from 4% to 32% at pediatric sites and 19% to 39% at adult sites. Baseline characteristics, including seizure precipitant, benzodiazepine dosing, and admission vital signs, provided limited discrimination for predicting intubation (area under the curve [AUC] 0.63). However, treatment at sites with an intubation rate in the highest (vs lowest) quartile strongly predicted endotracheal intubation independently of other treatment variables (adjusted odds ratio [aOR] 8.12, 95% confidence interval [CI] 3.08-21.4, model AUC 0.70). Site-specific variation was the factor most strongly associated with endotracheal intubation after adjustment for 20-minute (aOR 23.4, 95% CI 6.99-78.3, model AUC 0.88) and 60-minute (aOR 14.7, 95% CI 3.20-67.5, model AUC 0.98) neurologic recovery. CONCLUSIONS Endotracheal intubation after established status epilepticus is strongly associated with site-specific practice pattern variation, independently of baseline characteristics, and early neurologic recovery and should not alone serve as a clinical trial endpoint in established status epilepticus. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT01960075.
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Affiliation(s)
- Eric S Rosenthal
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC.
| | - Jordan J Elm
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - James Ingles
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Alexander J Rogers
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Thomas E Terndrup
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Maija Holsti
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Danny G Thomas
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Lynn Babcock
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Pamela J Okada
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Robert H Lipsky
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Joseph B Miller
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Robert W Hickey
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Megan E Barra
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Thomas P Bleck
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - James C Cloyd
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Robert Silbergleit
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Daniel H Lowenstein
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Lisa D Coles
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Jaideep Kapur
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - Shlomo Shinnar
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
| | - James M Chamberlain
- From the Division of Clinical Neurophysiology and Division of Neurocritical Care (E.S.R.), Department of Neurology, and Department of Pharmacy (M.E.B.), Massachusetts General Hospital, Boston; Department of Public Health Sciences (J.J.E., J.I.), Medical University of South Carolina, Charleston; Departments of Emergency Medicine (A.J.R., R.S.) and Pediatrics (A.J.R.), University of Michigan, Ann Arbor; Department of Emergency Medicine (T.E.T.), The Ohio State University Wexner Medical Center, Columbus; Division of Pediatric Emergency Medicine (M.H.), Department of Pediatrics, University of Utah, Salt Lake City; Department of Pediatrics (D.G.T.), Medical College of Wisconsin, Milwaukee; Division of Emergency Medicine (L.B.), Department of Pediatrics, University of Cincinnati, OH; Division of Pediatric Emergency Medicine (P.J.O.), Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX; Department of Neurosciences (R.H.L.), Inova Health System, Falls Church, VA; Department of Emergency Medicine (J.B.M.), Henry Ford Hospital, Detroit, MI; Division of Pediatric Emergency Medicine (R.W.H.), Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, PA; Feinberg School of Medicine (T.P.B.), Northwestern University and Rush Medical College, Chicago, IL; Department of Experimental and Clinical Pharmacology (J.C.C., L.D.C.), College of Pharmacy and Center for Orphan Drug Research, University of Minnesota, Minneapolis; Department of Neurology (D.H.L.), University of California, San Francisco; Department of Neurology (J.K.), University of Virginia, Charlottesville; Montefiore Medical Center (S.S.), Albert Einstein College of Medicine, Bronx, NY; and Division of Emergency Medicine (J.M.C.), Children's National Medical Center, Washington, DC
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16
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Dunnick J, Taft M, Tisherman RT, Nowalk AJ, Hickey RW, Wilson PM. Association of Bacteremia with Vaccination Status in Children Aged 2 to 36 Months. J Pediatr 2021; 232:207-213.e2. [PMID: 33453206 DOI: 10.1016/j.jpeds.2021.01.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 01/03/2021] [Accepted: 01/07/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the association between bacteremia and vaccination status in children aged 2-36 months presenting to a pediatric emergency department. STUDY DESIGN Retrospective cohort study of children aged 2-36 months with blood cultures obtained in the pediatric emergency department between January 2013 and December 2017. The exposure of interest was immunization status, defined as number of Haemophilus influenzae type B (Hib) and Streptococcus pneumoniae vaccinations, and the main outcome positive blood culture. Subjects with high-risk medical conditions were excluded. RESULTS Of 5534 encounters, 4742 met inclusion criteria. The incidence of bacteremia was 1.5%. The incidence of contaminated blood culture was 5.0%. The relative risk of bacteremia was 0.79 (95% CI 0.39-1.59) for unvaccinated and 1.20 (95% CI 0.52-2.75) for undervaccinated children relative to those who had received age-appropriate vaccines. Five children were found to have S pneumoniae bacteremia and 1 child had Hib bacteremia; all of these subjects had at least 3 sets of vaccinations. No vaccine preventable pathogens were isolated from blood cultures of unvaccinated children. We found no S pneumoniae or Hib in children 2-6 months of age who were not fully vaccinated due to age (95% CI 0-0.13%) and the contamination rate in this group was high compared with children 7-36 months (6.6% vs 3.7%). CONCLUSIONS Bacteremia in young children is an uncommon event. Contaminated blood cultures were more common than pathogens. Bacteremia from S pneumoniae or Hib is uncommon and, in this cohort, was independent of vaccine status.
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Affiliation(s)
- Jennifer Dunnick
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA.
| | - Maia Taft
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | | | - Andrew J Nowalk
- Division of Infectious Disease, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA; Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Paria M Wilson
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH; Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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17
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Ramgopal S, Zhou AZ, Hickey RW, Marin JR. Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache. J Child Neurol 2021; 36:475-481. [PMID: 33356803 DOI: 10.1177/0883073820979137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache. METHODS We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders. RESULTS Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters (P = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 (P < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders. CONCLUSION Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Amy Z Zhou
- Division of Emergency Medicine, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, 6619UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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18
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King CA, Brent D, Grupp-Phelan J, Casper TC, Dean JM, Chernick LS, Fein JA, Mahabee-Gittens EM, Patel SJ, Mistry RD, Duffy S, Melzer-Lange M, Rogers A, Cohen DM, Keller A, Shenoi R, Hickey RW, Rea M, Cwik M, Page K, McGuire TC, Wang J, Gibbons R. Prospective Development and Validation of the Computerized Adaptive Screen for Suicidal Youth. JAMA Psychiatry 2021; 78:540-549. [PMID: 33533908 PMCID: PMC7859874 DOI: 10.1001/jamapsychiatry.2020.4576] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The rate of suicide among adolescents is rising in the US, yet many adolescents at risk are unidentified and receive no mental health services. OBJECTIVE To develop and independently validate a novel computerized adaptive screen for suicidal youth (CASSY) for use as a universal screen for suicide risk in medical emergency departments (EDs). DESIGN, SETTING, AND PARTICIPANTS Study 1 of this prognostic study prospectively enrolled adolescent patients at 13 geographically diverse US EDs in the Pediatric Emergency Care Applied Research Network. They completed a baseline suicide risk survey and participated in 3-month telephone follow-ups. Using 3 fixed Ask Suicide-Screening Questions items as anchors and additional items that varied in number and content across individuals, we derived algorithms for the CASSY. In study 2, data were collected from patients at 14 Pediatric Emergency Care Applied Research Network EDs and 1 Indian Health Service hospital. Algorithms were independently validated in a prospective cohort of adolescent patients who also participated in 3-month telephone follow-ups. Adolescents aged 12 to 17 years were consecutively approached during randomly assigned shifts. EXPOSURES Presentation at an ED. MAIN OUTCOME AND MEASURE A suicide attempt between ED visit and 3-month follow-up, measured via patient and/or parent report. RESULTS The study 1 CASSY derivation sample included 2075 adolescents (1307 female adolescents [63.0%]; mean [SD] age, 15.1 [1.61] years) with 3-month follow-ups (72.9% retention [2075 adolescents]). The study 2 validation sample included 2754 adolescents (1711 female adolescents [62.1%]; mean [SD] age, 15.0 [1.65] years), with 3-month follow-ups (69.5% retention [2754 adolescents]). The CASSY algorithms had excellent predictive accuracy for suicide attempt (area under the curve, 0.89 [95% CI, 0.85-0.91]) in study 1. The mean number of adaptively administered items was 11 (range, 5-21). At a specificity of 80%, the CASSY had a sensitivity of 83%. It also demonstrated excellent accuracy in the study 2 validation sample (area under the curve, 0.87 [95% CI, 0.85-0.89]). In this study, the CASSY had a sensitivity of 82.4% for prediction of a suicide attempt at the 80% specificity cutoff established in study 1. CONCLUSIONS AND RELEVANCE In this study, the adaptive and personalized CASSY demonstrated excellent suicide attempt risk recognition, which has the potential to facilitate linkage to services.
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Affiliation(s)
- Cheryl A. King
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - David Brent
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | | | - Lauren S. Chernick
- Department of Emergency Medicine and Pediatrics, Columbia University Medical Center, New York, New York
| | - Joel A. Fein
- Center for Violence Prevention, Children’s Hospital of Philadelphia, Division of Emergency Medicine, University of Pennsylvania, Philadelphia
| | | | - Shilpa J. Patel
- Division of Emergency Medicine, Children’s National Hospital, Washington, DC
| | - Rakesh D. Mistry
- Department of Pediatrics–Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Susan Duffy
- Department of Emergency Medicine, Alpert Medical School at Brown University, Providence, Rhode Island,Department of Pediatrics, Alpert Medical School at Brown University, Providence, Rhode Island
| | | | - Alexander Rogers
- Department of Emergency Medicine, University of Michigan, Ann Arbor,Department of Pediatrics, University of Michigan, Ann Arbor
| | - Daniel M. Cohen
- Division of Emergency Medicine, Nationwide Children’s Hospital, Columbus, Ohio
| | - Allison Keller
- Department of Pediatric Emergency Medicine, The University of Utah, Salt Lake City
| | - Rohit Shenoi
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Robert W. Hickey
- Department of Pediatrics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Margaret Rea
- Medical Center at the University of California School of Medicine, Davis, Sacramento
| | - Mary Cwik
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kent Page
- The University of Utah School of Medicine, Salt Lake City
| | | | - Jiebiao Wang
- Department of Statistics and Data Science, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Robert Gibbons
- Department of Medicine, The University of Chicago, Chicago, Illinois,Department of Public Health Sciences (Biostatistics), The University of Chicago, Chicago, Illinois,Department of Psychiatry and Behavioral Neuroscience, The University of Chicago, Chicago, Illinois,Department of Comparative Human Development, The University of Chicago, Chicago, Illinois
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19
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Campbell AP, Ogokeh C, Lively JY, Staat MA, Selvarangan R, Halasa NB, Englund JA, Boom JA, Weinberg GA, Williams JV, McNeal M, Harrison CJ, Stewart LS, Klein EJ, Sahni LC, Szilagyi PG, Michaels MG, Hickey RW, Moffat ME, Pahud BA, Schuster JE, Weddle GM, Rha B, Fry AM, Patel M. Vaccine Effectiveness Against Pediatric Influenza Hospitalizations and Emergency Visits. Pediatrics 2020; 146:peds.2020-1368. [PMID: 33020249 DOI: 10.1542/peds.2020-1368] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Influenza A(H1N1)pdm09 viruses initially predominated during the US 2018-2019 season, with antigenically drifted influenza A(H3N2) viruses peaking later. We estimated vaccine effectiveness (VE) against laboratory-confirmed influenza-associated hospitalizations and emergency department (ED) visits among children in the New Vaccine Surveillance Network. METHODS We tested children 6 months to 17 years with acute respiratory illness for influenza using molecular assays at 7 pediatric hospitals (ED patients <5 years at 3 sites). Vaccination status sources were parental report, state immunization information systems and/or provider records for inpatients, and parental report alone for ED patients. We estimated VE using a test-negative design, comparing odds of vaccination among children testing positive versus negative for influenza using multivariable logistic regression. RESULTS Of 1792 inpatients, 226 (13%) were influenza-positive: 47% for influenza A(H3N2), 36% for A(H1N1)pdm09, 9% for A (not subtyped), and 7% for B viruses. Among 1944 ED children, 420 (22%) were influenza-positive: 48% for A(H3N2), 35% for A(H1N1)pdm09, 11% for A (not subtyped), and 5% for B viruses. VE was 41% (95% confidence interval [CI], 20% to 56%) against any influenza-related hospitalizations, 41% (95% CI, 11% to 61%) for A(H3N2), and 47% (95% CI, 16% to 67%) for A(H1N1)pdm09. VE was 51% (95% CI, 38% to 62%) against any influenza-related ED visits, 39% (95% CI, 15% to 56%) against A(H3N2), and 61% (95% CI, 44% to 73%) against A(H1N1)pdm09. CONCLUSIONS The 2018-2019 influenza vaccine reduced pediatric influenza A-associated hospitalizations and ED visits by 40% to 60%, despite circulation of a drifted A(H3N2) clade.
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Affiliation(s)
| | - Constance Ogokeh
- Influenza Division and
- Fellowship Program, Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee
| | - Joana Y Lively
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
- IHRC, Inc, Atlanta, Georgia
| | - Mary A Staat
- Department of Pediatrics, University of Cincinnati College of Medicine and Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rangaraj Selvarangan
- Department of Pathology and Laboratory Medicine, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
- Divisions of Infectious Diseases and
| | - Natasha B Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Janet A Englund
- Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Julie A Boom
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Geoffrey A Weinberg
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
| | - John V Williams
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Monica McNeal
- Department of Pediatrics, University of Cincinnati College of Medicine and Division of Infectious Disease, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christopher J Harrison
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Laura S Stewart
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eileen J Klein
- Department of Pediatrics, Seattle Children's Research Institute, Seattle, Washington
- Department of Pediatrics, School of Medicine, University of Washington, Seattle, Washington
| | - Leila C Sahni
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
- Texas Children's Hospital, Houston, Texas
| | - Peter G Szilagyi
- Department of Pediatrics, School of Medicine and Dentistry, University of Rochester, Rochester, New York
- Department of Pediatrics, University of California, Los Angeles and University of California, Los Angeles Mattel Children's Hospital, Los Angeles, California
| | - Marian G Michaels
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Robert W Hickey
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | | | - Barbara A Pahud
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Jennifer E Schuster
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Gina M Weddle
- Department of Pediatrics, School of Medicine, University of Pittsburgh and University of Pittsburgh Medical Center Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Brian Rha
- Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
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Abstract
BACKGROUND Headache is a common complaint among children presenting to the emergency department (ED) and can be due to serious neurologic and nonneurologic diagnoses (SNNDs). We sought to characterize the children discharged from the ED with headache found to have SNNDs at revisits. METHODS We performed a multicenter retrospective cohort study using data from 45 pediatric hospitals from October 1, 2015, to March 31, 2019. We included pediatric patients (≤18 years) discharged from the ED with a principal diagnosis of headache, excluding patients with concurrent or previous SNNDs or neurosurgeries. We identified rates and types of SNNDs diagnosed within 30 days of initial visit and compared these rates with those of control groups defined as patients with discharge diagnoses of cough, chest pain, abdominal pain, and soft tissue complaints. RESULTS Of 121 621 included patients (57% female, median age 12.4 years, interquartile range: 8.8-15.4), 608 (0.5%, 95% confidence interval: 0.5%-0.5%) were diagnosed with SNNDs within 30 days. Most were diagnosed at the first revisit (80.8%); 37.5% were diagnosed within 7 days. The most common SNNDs were benign intracranial hypertension, cerebral edema and compression, and seizures. A greater proportion of patients with SNNDs underwent neuroimaging, blood, and cerebrospinal fluid testing compared with those without SNNDs (P < .001 for each). The proportion of SNNDs among patients diagnosed with headache (0.5%) was higher than for control cohorts (0.0%-0.1%) (P < .001 for each). CONCLUSIONS A total 0.5% of pediatric patients discharged from the ED with headache were diagnosed with an SNND within 30 days. Further efforts to identify at-risk patients remain a challenge.
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Affiliation(s)
- Amy Z Zhou
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois;
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and.,Department of Emergency Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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Chung JR, Flannery B, Gaglani M, Smith ME, Reis EC, Hickey RW, Jackson ML, Jackson LA, Belongia EA, McLean HQ, Martin ET, Segaloff HE, Kim SS, Patel MM. Patterns of Influenza Vaccination and Vaccine Effectiveness Among Young US Children Who Receive Outpatient Care for Acute Respiratory Tract Illness. JAMA Pediatr 2020; 174:705-713. [PMID: 32364599 PMCID: PMC7199168 DOI: 10.1001/jamapediatrics.2020.0372] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The burden of influenza among young children is high, and influenza vaccination is the primary strategy to prevent the virus and its complications. Less is known about differences in clinical protection following 1 vs 2 doses of initial influenza vaccination. OBJECTIVES To describe patterns of influenza vaccination among young children who receive outpatient care for acute respiratory tract illness in the US and compare vaccine effectiveness (VE) against medically attended laboratory-confirmed influenza by number of influenza vaccine doses received. DESIGN This test-negative case-control study was conducted in outpatient clinics, including emergency departments, at 5 sites of the US Influenza Vaccine Effectiveness Network during the 2014-2015 through 2017-2018 influenza seasons. The present study was performed from November 5, 2014, to April 12, 2018, during periods of local influenza circulation. Children aged 6 months to 8 years with an acute respiratory tract illness with cough who presented for outpatient care within 7 days of illness onset were included. All children were tested using real-time, reverse-transcriptase polymerase chain reaction for influenza for research purposes. EXPOSURES Vaccination in the enrollment season with either 1 or 2 doses of inactivated influenza vaccine as documented from electronic medical records, including state immunization information systems. MAIN OUTCOMES AND MEASURES Medically attended acute respiratory tract infection with real-time, reverse-transcriptase polymerase chain reaction testing for influenza. RESULTS Of 7533 children, 3480 children (46%) were girls, 4687 children (62%) were non-Hispanic white, and 4871 children (65%) were younger than 5 years. A total of 3912 children (52%) were unvaccinated in the enrollment season, 2924 children (39%) were fully vaccinated, and 697 children (9%) were partially vaccinated. Adjusted VE against any influenza was 51% (95% CI, 44%-57%) among fully vaccinated children and 41% (95% CI, 25%-54%) among partially vaccinated children. Among 1519 vaccine-naive children aged 6 months to 2 years, the VE of 2 doses in the enrollment season was 53% (95% CI, 28%-70%), and the VE of 1 dose was 23% (95% CI, -11% to 47%); those who received 2 doses were less likely to test positive for influenza compared with children who received only 1 dose (adjusted odds ratio, 0.57; 95% CI, 0.35-0.93). CONCLUSIONS AND RELEVANCE Consistent with US influenza vaccine policy, receipt of the recommended number of doses resulted in higher VE than partial vaccination in 4 influenza seasons. Efforts to improve 2-dose coverage for previously unvaccinated children may reduce the burden of influenza in this population.
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Affiliation(s)
- Jessie R. Chung
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Brendan Flannery
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manjusha Gaglani
- Texas A&M University Health Science Center College of Medicine, Temple,Baylor Scott & White Health Research Institute, Temple, Texas
| | | | - Evelyn C. Reis
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert W. Hickey
- Department of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael L. Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Lisa A. Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington
| | - Edward A. Belongia
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Huong Q. McLean
- Center for Clinical Epidemiology & Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Emily T. Martin
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Hannah E. Segaloff
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor
| | - Sara S. Kim
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manish M. Patel
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia
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Rha B, Lively JY, Englund JA, Staat MA, Weinberg GA, Selvarangan R, Halasa NB, Williams JV, Boom JA, Sahni LC, Michaels MG, Stewart LS, Harrison CJ, Szilagyi PG, McNeal MM, Klein EJ, Strelitz B, Lacombe K, Schlaudecker E, Moffatt ME, Schuster JE, Pahud BA, Weddle G, Hickey RW, Avadhanula V, Wikswo ME, Hall AJ, Curns AT, Gerber SI, Langley G. Severe Acute Respiratory Syndrome Coronavirus 2 Infections in Children: Multicenter Surveillance, United States, January-March 2020. J Pediatric Infect Dis Soc 2020; 9:609-612. [PMID: 32556327 PMCID: PMC7337823 DOI: 10.1093/jpids/piaa075] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 06/15/2020] [Indexed: 12/30/2022]
Abstract
Previous reports of coronavirus disease 2019 among children in the United States have been based on health jurisdiction reporting. We performed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing on children enrolled in active, prospective, multicenter surveillance during January-March 2020. Among 3187 children, only 4 (0.1%) SARS-CoV-2-positive cases were identified March 20-31 despite evidence of rising community circulation.
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Affiliation(s)
- Brian Rha
- CDC COVID-19 Response Team,Corresponding author: Brian Rha, MD, MSPH, for the CDC COVID-19 Response Team, [], 404-639-3972
| | - Joana Y Lively
- CDC COVID-19 Response Team,IHRC Inc., contracting agency to the Division of Viral Diseases, Atlanta, Georgia
| | | | - Mary A Staat
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Geoffrey A Weinberg
- University of Rochester School of Medicine and Dentistry, Rochester, New York
| | | | | | - John V Williams
- UPMC Children's Hospital of Pittsburgh, UPSOM, Pittsburgh, Pennsylvania
| | - Julie A Boom
- Texas Children's Hospital, Houston, Texas,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Leila C Sahni
- Texas Children's Hospital, Houston, Texas,Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Marian G Michaels
- UPMC Children's Hospital of Pittsburgh, UPSOM, Pittsburgh, Pennsylvania
| | | | | | - Peter G Szilagyi
- Department of Pediatrics, UCLA Mattel Children's Hospital, University of California at Los Angeles, Los Angeles, CA
| | - Monica M McNeal
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Elizabeth Schlaudecker
- Department of Pediatrics, University of Cincinnati, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Gina Weddle
- UMKC-SOM, Children's Mercy, Kansas City, Missouri
| | - Robert W Hickey
- UPMC Children's Hospital of Pittsburgh, UPSOM, Pittsburgh, Pennsylvania
| | - Vasanthi Avadhanula
- Department of Molecular Virology and Microbiology, Baylor College of Medicine, Houston, Texas
| | | | | | | | | | - Gayle Langley
- CDC COVID-19 Response Team,Alternate corresponding author: Gayle Langley, MD, MPH, for the CDC COVID-19 Response Team, [], 404.639.8092
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23
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Ramgopal S, Noorbakhsh KA, Pruitt CM, Aronson PL, Alpern ER, Hickey RW. Outcomes of Young Infants with Hypothermia Evaluated in the Emergency Department. J Pediatr 2020; 221:132-137.e2. [PMID: 32446472 DOI: 10.1016/j.jpeds.2020.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 02/11/2020] [Accepted: 03/02/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To assess the prevalence of serious infections and mortality among infants ≤90 days of age presenting to the emergency department with hypothermia. STUDY DESIGN We performed a cross-sectional cohort study of infants ≤90 days presenting to any of 40 EDs in the Pediatric Health Information Systems between January 1, 2009, and December 31, 2018. Infants with an International Classification of Diseases, ninth or tenth edition, admission/discharge diagnosis code of hypothermia were included. We determined the prevalence of serious bacterial infection (urinary tract infection, bacteremia, and/or bacterial meningitis), pneumonia, herpes simplex virus (HSV) infection, and emergency department/hospital mortality. RESULTS We included 3565 infants (1633 male [50.9%] and 3225 ≤30 days of age [90.5%]). Most (65.0%) presented in the first week of life. There were 389 infants (10.8%) with a complex chronic condition. The prevalence of serious bacterial infection was 8.0% (n = 284), including 2.4% (n = 87) with urinary tract infection, 5.6% (n = 199) with bacteremia, and 0.3% (n = 11) with bacterial meningitis. There were 7 patients (0.2%) with neonatal HSV and 9 (0.3%) with pneumonia; 0.2% (n = 6) died. The presence of a complex chronic condition was associated with the presence of serious bacterial infection (P < .001) and was present in 3 of 6 patients who died. In a sensitivity analysis including patients with any diagnosis code of hypothermia (n = 8122), 14.9% had serious bacterial infection, 0.6% had HSV, and 3.3% had pneumonia; 2.0% died. CONCLUSIONS Of infants with hypothermia ≤90 days of age, 8.3% had serious bacterial infections or HSV. Compared with literature from febrile infants, hypothermia is associated with a high mortality rate. Complex chronic conditions were particularly associated with poor outcomes. Additional research is required to risk stratify young infants with hypothermia.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL.
| | - Kathleen A Noorbakhsh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Christopher M Pruitt
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Paul L Aronson
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT; Department of Emergency Medicine, Section of Pediatric Emergency Medicine, Yale School of Medicine, New Haven, CT
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Robert W Hickey
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA
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24
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Madsen JR, Boyle TP, Neuman MI, Park EH, Tamber MS, Hickey RW, Heuer GG, Zorc JJ, Leonard JR, Leonard JC, Keating R, Chamberlain JM, Frim DM, Zakrzewski P, Klinge P, Merck LH, Piatt J, Bennett JE, Sandberg DI, Boop FA, Hameed MQ. Diagnostic Accuracy of Non-Invasive Thermal Evaluation of Ventriculoperitoneal Shunt Flow in Shunt Malfunction: A Prospective, Multi-Site, Operator-Blinded Study. Neurosurgery 2020; 87:939-948. [PMID: 32459841 PMCID: PMC7566379 DOI: 10.1093/neuros/nyaa128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/27/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Thermal flow evaluation (TFE) is a non-invasive method to assess ventriculoperitoneal shunt function. Flow detected by TFE is a negative predictor of the need for revision surgery. Further optimization of testing protocols, evaluation in multiple centers, and integration with clinical and imaging impressions prompted the current study. OBJECTIVE To compare the diagnostic accuracy of 2 TFE protocols, with micropumper (TFE+MP) or without (TFE-only), to neuro-imaging in patients emergently presenting with symptoms concerning for shunt malfunction. METHODS We performed a prospective multicenter operator-blinded trial of a consecutive series of patients who underwent evaluation for shunt malfunction. TFE was performed, and preimaging clinician impressions and imaging results were recorded. The primary outcome was shunt obstruction requiring neurosurgical revision within 7 d. Non-inferiority of the sensitivity of TFE vs neuro-imaging for detecting shunt obstruction was tested using a prospectively determined a priori margin of −2.5%. RESULTS We enrolled 406 patients at 10 centers. Of these, 68/348 (20%) evaluated with TFE+MP and 30/215 (14%) with TFE-only had shunt obstruction. The sensitivity for detecting obstruction was 100% (95% CI: 88%-100%) for TFE-only, 90% (95% CI: 80%-96%) for TFE+MP, 76% (95% CI: 65%-86%) for imaging in TFE+MP cohort, and 77% (95% CI: 58%-90%) for imaging in the TFE-only cohort. Difference in sensitivities between TFE methods and imaging did not exceed the non-inferiority margin. CONCLUSION TFE is non-inferior to imaging in ruling out shunt malfunction and may help avoid imaging and other steps. For this purpose, TFE only is favored over TFE+MP.
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Affiliation(s)
- Joseph R Madsen
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tehnaz P Boyle
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
- Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Mark I Neuman
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eun-Hyoung Park
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Mandeep S Tamber
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- British Columbia Children's Hospital, University of British Columbia, Vancouver, Canada
| | - Robert W Hickey
- Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Gregory G Heuer
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph J Zorc
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey R Leonard
- Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio
| | - Julie C Leonard
- Nationwide Children's Hospital, Ohio State University College of Medicine, Columbus, Ohio
| | - Robert Keating
- Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - James M Chamberlain
- Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| | - David M Frim
- The University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Paula Zakrzewski
- The University of Chicago Comer Children's Hospital, Chicago, Illinois
| | - Petra Klinge
- Rhode Island Hospital, Brown University, Providence, Rhode Island
| | - Lisa H Merck
- Rhode Island Hospital, Brown University, Providence, Rhode Island
- University of Florida College of Medicine, Gainesville, Florida
| | - Joseph Piatt
- Alfred I. DuPont Hospital for Children, Nemours Children's Health System, Wilmington, Delaware
| | - Jonathan E Bennett
- Alfred I. DuPont Hospital for Children, Nemours Children's Health System, Wilmington, Delaware
| | - David I Sandberg
- University of Texas Health Science Center at Houston, McGovern Medical School, Houston, Texas
| | - Frederick A Boop
- University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Q Hameed
- Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Abstract
OBJECTIVE To identify whether a high PaO2 (hyperoxemia) at the time of presentation to the PICU is associated with in-hospital mortality. DESIGN Single-center observational study. SETTING Quaternary-care PICU. PATIENTS Encounters admitted between January 1, 2009, and December 31, 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Encounters with a measured PaO2 were included. To account for severity of illness upon presentation, we calculated a modified Pediatric Risk of Mortality IV score excluding PaO2 for each encounter, calibrated for institutional data. Logistic regression was used to determine whether hyperoxemia (PaO2 ≥ 300 torr [39.99 kPa]) in the 12 hours surrounding PICU admission was associated with in-hospital mortality. We reperformed our analysis using a cutoff for hyperoxemia obtained by comparisons of observed versus predicted mortality when encounters were classified by highest PaO2 in 50 torr (6.67 kPa) bins. Results are reported as adjusted odds ratios with 95% CIs. Of 23,719 encounters, 4,093 had a PaO2 recorded in the period -6 to +6 hours after admission. Two hundred seventy-four of 4,093 (6.7%) had in-hospital mortality. The prevalence of hyperoxemia increased with rising modified Pediatric Risk of Mortality IV and was not associated with mortality in multivariable models (adjusted odds ratio, 1.38; 95% CI, 0.98-1.93). When using a higher cutoff of hyperoxemia derived from comparison of observed versus predicted rates of mortality of greater than or equal to 550 torr (73.32 kPa), hyperoxemia was associated with mortality (adjusted odds ratio, 2.78; 95% CI, 2.54-3.05). CONCLUSIONS A conventional threshold for hyperoxemia at presentation to the PICU was not associated with in-hospital mortality in a model using a calibrated acuity score. Extreme states of hyperoxemia (≥ 73.32 kPa) were significantly associated with in-hospital mortality. Prospective research is required to identify if hyperoxemia before and/or after PICU admission contributes to poor outcomes.
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Affiliation(s)
- Sriram Ramgopal
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert W. Hickey
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Alicia K. Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Shekhar Venkataraman
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Robert S. B. Clark
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Christopher M. Horvat
- Department of Pediatrics, University of Pittsburgh School of Medicine, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA.,Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA.,Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
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26
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Shaikh N, Martin JM, Hoberman A, Skae M, Milkovich L, McElheny C, Hickey RW, Gabriel LV, Kearney DH, Majd M, Shalaby-Rana E, Tseng G, Kolls J, Horne W, Huo Z, Shope TR. Biomarkers that differentiate false positive urinalyses from true urinary tract infection. Pediatr Nephrol 2020; 35:321-329. [PMID: 31758242 PMCID: PMC6942213 DOI: 10.1007/s00467-019-04403-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/26/2019] [Accepted: 10/16/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND The specificity of the leukocyte esterase test (87%) is suboptimal. The objective of this study was to identify more specific screening tests that could reduce the number of children who unnecessarily receive antimicrobials to treat a presumed urinary tract infection (UTI). METHODS Prospective cross-sectional study to compare inflammatory proteins in blood and urine samples collected at the time of a presumptive diagnosis of UTI. We also evaluated serum RNA expression in a subset. RESULTS We enrolled 200 children; of these, 89 were later demonstrated not to have a UTI based on the results of the urine culture obtained. Urinary proteins that best discriminated between children with UTI and no UTI were involved in T cell response proliferation (IL-9, IL-2), chemoattractants (CXCL12, CXCL1, CXCL8), the cytokine/interferon pathway (IL-13, IL-2, INFγ), or involved in innate immunity (NGAL). The predictive power (as measured by the area under the curve) of a combination of four urinary markers (IL-2, IL-9, IL-8, and NGAL) was 0.94. Genes in the pathways related to inflammation were also upregulated in serum of children with UTI. CONCLUSIONS Urinary proteins involved in the inflammatory response may be useful in identifying children with false positive results with current screening tests for UTI; this may reduce unnecessary treatment.
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Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA. .,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA.
| | - Judith M Martin
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Alejandro Hoberman
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Megan Skae
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Linette Milkovich
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Christi McElheny
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Lucine V Gabriel
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Diana H Kearney
- Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
| | - Massoud Majd
- Children's National Health System, Washington, USA
| | | | - George Tseng
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jay Kolls
- Tulane School of Medicine, New Orleans, PA, USA
| | - William Horne
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA
| | - Zhiguang Huo
- Department of Biostatistics, Biostatistics, College of Public Health & Health Professions and College of Medicine, University of Florida, Gainesville, USA
| | - Timothy R Shope
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, USA.,Division of General Academic Pediatrics, Children's Hospital of Pittsburgh of UPMC, One Children's Hospital Drive, 4401 Penn Ave, Pittsburgh, PA, 15224, USA
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27
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Ramgopal S, Dezfulian C, Hickey RW, Au AK, Venkataraman S, Clark RSB, Horvat CM. Association of Severe Hyperoxemia Events and Mortality Among Patients Admitted to a Pediatric Intensive Care Unit. JAMA Netw Open 2019; 2:e199812. [PMID: 31433484 PMCID: PMC6707098 DOI: 10.1001/jamanetworkopen.2019.9812] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE A high Pao2, termed hyperoxemia, is postulated to have deleterious health outcomes. To date, the association between hyperoxemia during the ongoing management of critical illness and mortality has been incompletely evaluated in children. OBJECTIVE To examine whether severe hyperoxemia events are associated with mortality among patients admitted to a pediatric intensive care unit (PICU). DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted over a 10-year period (January 1, 2009, to December 31, 2018); all 23 719 PICU encounters at a quaternary children's hospital with a documented arterial blood gas measurement were evaluated. EXPOSURES Severe hyperoxemia, defined as Pao2 level greater than or equal to 300 mm Hg (40 kPa). MAIN OUTCOMES AND MEASURES The highest Pao2 values during hospitalization were dichotomized according to the definition of severe hyperoxemia and assessed for association with in-hospital mortality using logistic regression models incorporating a calibrated measure of multiple organ dysfunction, extracorporeal life support, and the total number of arterial blood gas measurements obtained during an encounter. RESULTS Of 23 719 PICU encounters during the inclusion period, 6250 patients (13 422 [56.6%] boys; mean [SD] age, 7.5 [6.6] years) had at least 1 measured Pao2 value. Severe hyperoxemia was independently associated with in-hospital mortality (adjusted odds ratio [aOR], 1.78; 95% CI, 1.36-2.33; P < .001). Increasing odds of in-hospital mortality were observed with 1 (aOR, 1.47; 95% CI, 1.05-2.08; P = .03), 2 (aOR, 2.01; 95% CI, 1.27-3.18; P = .002), and 3 or more (aOR, 2.53; 95% CI, 1.62-3.94; P < .001) severely hyperoxemic Pao2 values obtained greater than or equal to 3 hours apart from one another compared with encounters without hyperoxemia. A sensitivity analysis examining the hypothetical outcomes of residual confounding indicated that an unmeasured binary confounder with an aOR of 2 would have to be present in 37% of the encounters with severe hyperoxemia and 0% of the remaining cohort to fail to reject the null hypothesis (aOR of severe hyperoxemia, 1.31; 95% CI, 0.99-1.72). CONCLUSIONS AND RELEVANCE Greater numbers of severe hyperoxemia events appeared to be associated with increased mortality in this large, diverse cohort of critically ill children, supporting a possible exposure-response association between severe hyperoxemia and outcome in this population. Although further prospective evaluation appears to be warranted, this study's findings suggest that guidelines for ongoing management of critically ill children should take into consideration the possible detrimental effects of severe hyperoxemia.
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Affiliation(s)
- Sriram Ramgopal
- Department of Pediatrics, University of Pittsburgh School of Medicine; UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cameron Dezfulian
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert W. Hickey
- Department of Pediatrics, University of Pittsburgh School of Medicine; UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Alicia K. Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shekhar Venkataraman
- Department of Pediatrics, University of Pittsburgh School of Medicine; UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert S. B. Clark
- Department of Pediatrics, University of Pittsburgh School of Medicine; UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christopher M. Horvat
- Department of Pediatrics, University of Pittsburgh School of Medicine; UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Health Informatics for Clinical Effectiveness, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Shaikh N, Martin JM, Hoberman A, Skae M, Milkovich L, Nowalk A, McElheny C, Hickey RW, Kearney D, Majd M, Shalaby-Rana E, Tseng G, Alcorn JF, Kolls J, Kurs-Lasky M, Huo Z, Horne W, Lockhart G, Pohl H, Shope TR. Host and Bacterial Markers that Differ in Children with Cystitis and Pyelonephritis. J Pediatr 2019; 209:146-153.e1. [PMID: 30905425 PMCID: PMC6535366 DOI: 10.1016/j.jpeds.2019.01.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine whether treatment for urinary tract infections in children could be individualized using biomarkers for acute pyelonephritis. STUDY DESIGN We enrolled 61 children with febrile urinary tract infections, collected blood and urine samples, and performed a renal scan within 2 weeks of diagnosis to identify those with pyelonephritis. Renal scans were interpreted centrally by 2 experts. We measured inflammatory proteins in blood and urine using LUMINEX or an enzyme-linked immunosorbent assay. We evaluated serum RNA expression using RNA sequencing in a subset of children. Finally, for children with Escherichia coli isolated from urine cultures, we performed a polymerase chain reaction for 4 previously identified virulence genes. RESULTS Urinary markers that best differentiated pyelonephritis from cystitis included chemokine (C-X-C motif) ligand (CXCL)1, CXCL9, CXCL12, C-C motif chemokine ligand 2, INF γ, and IL-15. Serum procalcitonin was the best serum marker for pyelonephritis. Genes in the interferon-γ pathway were upregulated in serum of children with pyelonephritis. The presence of E coli virulence genes did not correlate with pyelonephritis. CONCLUSIONS Immune response to pyelonephritis and cystitis differs quantitatively and qualitatively; this may be useful in differentiating these 2 conditions.
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Affiliation(s)
- Nader Shaikh
- Department of Pediatrics, University of Pittsburgh School of Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, University of Pittsburgh, Pittsburgh, PA.
| | - Judith M. Martin
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | - Alejandro Hoberman
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | - Megan Skae
- Children’s Hospital of Pittsburgh of UPMC
| | | | - Andrew Nowalk
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | - Christi McElheny
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh School of Medicine
| | - Robert W. Hickey
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
| | | | | | | | - George Tseng
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh
| | | | | | | | - Zhiguang Huo
- Department of Biostatistics, College of Public Health & Health Professions, University of Florida
| | | | | | | | - Timothy R. Shope
- University of Pittsburgh School of Medicine,Children’s Hospital of Pittsburgh of UPMC
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Carden MA, Brousseau DC, Ahmad FA, Bennett J, Bhatt S, Bogie A, Brown K, Casper TC, Chapman LL, Chumpitazi CE, Cohen D, Dampier C, Ellison AM, Grasemann H, Hickey RW, Hsu LL, Leibovich S, Powell E, Richards R, Sarnaik S, Weiner DL, Morris CR. Normal saline bolus use in pediatric emergency departments is associated with poorer pain control in children with sickle cell anemia and vaso-occlusive pain. Am J Hematol 2019; 94:689-696. [PMID: 30916794 DOI: 10.1002/ajh.25471] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/24/2019] [Accepted: 03/25/2019] [Indexed: 11/07/2022]
Abstract
Vaso-occlusive pain events (VOE) are the leading cause of emergency department (ED) visits in sickle cell anemia (SCA). This study assessed the variability in use of intravenous fluids (IVFs), and the association of normal saline bolus (NSB), on pain and other clinical outcomes in children with SCA, presenting to pediatric emergency departments (PED) with VOE. Four-hundred charts of children age 3-21 years with SCA/VOE receiving parenteral opioids at 20 high-volume PEDs were evaluated in a retrospective study. Data on type and amount of IVFs used were collected. Patients were divided into two groups: those who received NSB and those who did not. The association of NSB use on change in pain scores and admission rates was evaluated. Among 400 children studied, 261 (65%) received a NSB. Mean age was 13.8 ± 4.9 years; 46% were male; 92% had hemoglobin-SS. The IVFs (bolus and/or maintenance) were used in 84% of patients. Eight different types of IVFs were utilized and IVF volume administered varied widely. Mean triage pain scores were similar between groups, but improvement in pain scores from presentation-to-ED-disposition was smaller in the NSB group (2.2 vs 3.0, P = .03), while admission rates were higher (71% vs 59%, P = .01). Use of NSB remained associated with poorer final pain scores and worse change in pain scores in our multivariable model. In conclusion, wide variations in practice utilizing IVFs are common. NSB is given to >50% of children with SCA/VOE, but is associated with poorer pain control; a controlled prospective trial is needed to determine causality.
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Affiliation(s)
- Marcus A. Carden
- Departments of Pediatrics and MedicineUniversity of North Carolina at Chapel Hill School of Medicine Chapel Hill North Carolina
| | - David C. Brousseau
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Medical College of Wisconsin Milwaukee Wisconsin
| | - Fahd A. Ahmad
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Washington University School of Medicine St. Louis Missouri
| | - Jonathan Bennett
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Alfred I. DuPont Hospital for Children Wilmington Delaware
| | - Seema Bhatt
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center Cincinnati Ohio
| | - Amanda Bogie
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Oklahoma Health Sciences Center Oklahoma City Oklahoma
| | - Kathleen Brown
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's National Medical Center Washington District of Columbia
| | - Theron Charles Casper
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah Salt Lake City Utah
| | | | - Corrie E. Chumpitazi
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Baylor College of Medicine Houston Texas
| | - Daniel Cohen
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Nationwide Children's Hospital Columbus Ohio
| | - Carlton Dampier
- Department of Pediatrics, Division of Hematology/OncologyEmory University School of Medicine Atlanta Georgia
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The Aflac Cancer and Blood Disorders Center of Children's Healthcare Atlanta Georgia
| | - Angela M. Ellison
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The Children's Hospital of Philadelphia Philadelphia Pennsylvania
| | - Hartmut Grasemann
- Department of Pediatrics, Division of Respiratory Medicine, The Hospital for Sick Children Toronto Ontario Canada
| | - Robert W. Hickey
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh of UPMC Pittsburgh Pennsylvania
| | - Lewis L. Hsu
- Department of Pediatrics, Division of Pediatric Hematology and OncologyUniversity of Illinois at Chicago Chicago Illinois
| | - Sara Leibovich
- Department of Pediatrics, Division of Pediatric Emergency Medicine, UCSF‐Benioff Children's Hospital at Oakland Oakland California
| | - Elizabeth Powell
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago Chicago Illinois
| | - Rachel Richards
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah Salt Lake City Utah
| | - Syana Sarnaik
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Hospital of Michigan Detroit Michigan
| | - Debra L. Weiner
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Boston Children's Hospital Boston Massachusetts
| | - Claudia R. Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
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Perry MC, Yaeger SK, Toto RL, Suresh S, Hickey RW. A Modern Epidemic: Increasing Pediatric Emergency Department Visits and Admissions for Headache. Pediatr Neurol 2018; 89:19-25. [PMID: 30343832 PMCID: PMC8485652 DOI: 10.1016/j.pediatrneurol.2018.07.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/28/2018] [Accepted: 07/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Headaches represent 0.9% to 2.6% of visits to a pediatric emergency department (PED). We noted a trend of increasing visits for headache in our tertiary care PED and sought to further characterize this trend. METHODS We identified PED visits with International Classification of Disease, Ninth Revision, Clinical Modification diagnoses for headache at 25 hospitals in Pediatric Health Information System between 2003 and 2013. To further characterize demographics and treatment trends over time we used the electronic health record in our emergency department to identify children ages four to 18 between January 2007 and December 2014 with International Classification of Disease, Ninth Revision codes for headache: a random sample of 50 visits per year were chosen for chart review. RESULTS Pediatric Health Information System visits for headache increased by 166% (18,041 in 2003 and 48,020 in 2013); by comparison, total PED visits increased by 57.6%. The percent admission increased by 300% (2020 admissions in 2003 and 8087 admissions in 2013). At our hospital, headache visits increased 111% from 896 visits in 2007 to 1887 visits in 2014; total PED visits increased 30.2%. The admission percentage for headache increased 187% with 156 admissions in 2007 and 448 in 2014. Management over time differed in the frequency of head computed tomography which decreased 3.7% per year (r = -0.93, 95% CI -0.99, -0.64) from 34% in 2007 to 18% in 2014. CONCLUSION Pediatric emergency department visits for headache are increasing and a growing proportion of these patients are admitted. This finding identifies a potential patient population to target for interventions to improve outpatient management and reduce pediatric emergency department utilization.
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Affiliation(s)
- Michelle C Perry
- A Children's Hospital of Pittsburgh of UPMC, Department of Pediatrics, Pittsburgh, Pennsylvania.
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Ramgopal S, Brungo LB, Bykowski MR, Pitetti RD, Hickey RW. Dog bites in a U.S. county: age, body part and breed in paediatric dog bites. Acta Paediatr 2018; 107:893-899. [PMID: 29331048 DOI: 10.1111/apa.14218] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Revised: 12/15/2017] [Accepted: 01/09/2018] [Indexed: 11/28/2022]
Abstract
AIM To compare characteristics of gender, age, body part and breed in dog bites. METHODS We reviewed 14 956 dog bites (4195 paediatric) reported to the Allegheny County Health Department, USA, between 2007 and 2015. Using predefined age groups, we performed linear regression to assess for subject age and bite frequency and used binary logistic regression to evaluate for differences in gender and body part. We used chi-squared test with Bonferroni correction to evaluate for differences in reported breeds with age. RESULTS There was a negative correlation (-0.80, r2 = 0.64) between age and bite frequency. Children 0-3 years had a higher odds ratio (OR) of bites to the face [21.12, 95% confidence interval (CI): 17.61-25.33] and a lower OR of bites to the upper (OR: 0.14, 95% CI: 0.12-0.18) and lower (OR: 0.19, 95% CI: 0.14-0.27) extremities. 'Pit bulls' accounted for 27.2% of dog bites and were more common in children 13-18 years (p < 0.01). Shih-Tzu bites were more common in children three years of age and younger (p < 0.01). CONCLUSION Dog bites occur with higher frequency at younger ages, and head and neck injuries are more common in younger children. Pit bull bites are more common in adolescents and Shih-Tzu bites more common in younger children.
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Affiliation(s)
- Sriram Ramgopal
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh; Pittsburgh PA USA
| | - Lauren Bealafeld Brungo
- Infectious Disease Program; Bureau of Community Health Promotion and Disease Prevention; Allegheny County Health Department; Pittsburgh PA USA
| | - Michael R. Bykowski
- Department of Plastic Surgery; University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh; Pittsburgh PA USA
| | - Raymond D. Pitetti
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh; Pittsburgh PA USA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh; Pittsburgh PA USA
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32
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Yaeger SK, Perry MC, Caperell K, Coffman KA, Hickey RW. In reply:. Ann Emerg Med 2017; 70:927-928. [DOI: 10.1016/j.annemergmed.2017.07.475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Indexed: 11/29/2022]
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Yaeger SK, Perry MC, Caperell K, Coffman KA, Hickey RW. Ropivacaine Intramuscular Paracervical Injections for Pediatric Headache: A Randomized Placebo-Controlled Trial. Ann Emerg Med 2017; 70:323-330. [DOI: 10.1016/j.annemergmed.2017.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2016] [Revised: 02/24/2017] [Accepted: 03/03/2017] [Indexed: 11/28/2022]
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Tavarez MM, Ayers B, Jeong JH, Coombs CM, Thompson A, Hickey RW. Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department. Acad Emerg Med 2017; 24:948-956. [PMID: 28470786 DOI: 10.1111/acem.13211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/07/2017] [Accepted: 04/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. METHODS We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders. RESULTS There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods. CONCLUSIONS Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.
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Affiliation(s)
- Melissa M. Tavarez
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Brandon Ayers
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
| | - Jong H. Jeong
- Department of Biostatistics; Graduate School of Public Health; University of Pittsburgh; Pittsburgh PA
| | - Carmen M. Coombs
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Ann Thompson
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Robert W. Hickey
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
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Sufrinko AM, Kontos AP, Apps JN, McCrea M, Hickey RW, Collins MW, Thomas DG. The Effectiveness of Prescribed Rest Depends on Initial Presentation After Concussion. J Pediatr 2017; 185:167-172. [PMID: 28365025 DOI: 10.1016/j.jpeds.2017.02.072] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/18/2017] [Accepted: 02/27/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To evaluate if patients with signs of injury respond differently to prescribed rest after concussion compared with patients with symptoms only. STUDY DESIGN Secondary analysis was completed of a prospective randomized controlled trial (NCT01101724) of pediatric concussion patients aged 11-18 years. Patients completed computerized neurocognitive testing and standardized balance assessment at the emergency department within 24 hours of injury and on follow-up (3 and 10 days). Patients were randomized to rest or usual care and completed activity and symptom diaries for 10 days after injury. A series of 2?×?2 ANOVAs with grouping factors of patient group (symptoms, signs) and treatment arm (prescribed rest, standard of care) were used to examine differences on clinical measures. Univariate nonparametric test (ie, ?2 with ORs and 95% CIs) was used to examine the association between treatment arm and symptom status 1-9 days after injury. RESULTS A 2?×?2 factorial ANOVA revealed a significant patient group × treatment arm interaction for symptom score at 3 days after injury (F?=?6.31, P?=?.01, ?2?=?0.07). Prescribed rest increased the likelihood of still being symptomatic at days 1-6 and 8 (P?<?.05) for the symptoms group. Rest was beneficial for patients in the signs group on verbal memory performance (t?=??2.28, P?=?.029), but not for the symptoms group. CONCLUSION Compared with patients with signs of injury, patients with predominantly symptoms were more likely to remain symptomatic after injury if prescribed rest, whereas patients with signs of injury benefited from rest after a concussion. Individualized treatment planning after concussion should start in the emergency department. TRIAL REGISTRATION ClinicalTrials.gov: NCT01101724.
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Affiliation(s)
- Alicia M Sufrinko
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Anthony P Kontos
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jennifer N Apps
- Department of Psychiatry and Behavioral Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Robert W Hickey
- Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI.
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Lewis J, Arora G, Tudorascu DL, Hickey RW, Saladino RA, Manole MD. Acute Management of Refractory and Unstable Pediatric Supraventricular Tachycardia. J Pediatr 2017; 181:177-182.e2. [PMID: 27912926 DOI: 10.1016/j.jpeds.2016.10.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/16/2016] [Accepted: 10/17/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To characterize the management of acute pediatric supraventricular tachycardia (SVT), placing special emphasis on infants, patients refractory to adenosine (refractory SVT), and patients with hypotension, poor perfusion, or altered mental status (unstable SVT). STUDY DESIGN Retrospective cohort study of patients 0-18 years of age without congenital heart disease who presented to our pediatric hospital from January 2003 to December 2012 for the treatment of acute SVT. Multiple logistic regression was applied to identify whether age was a risk factor for different SVT therapies. Model fit and residuals also were examined. RESULTS We identified 179 episodes for SVT. First dose of adenosine was effective in 72 (56%) episodes, and a second dose was effective in 27 of 54 (50%) episodes, leaving 27 (15%) episodes with refractory SVT. The response to the first dose of adenosine increased proportionally with age (OR 1.13, 95% CI 1.05-1.2). Only 1 of 17 episodes in infants responded to the first dose of adenosine. Refractory SVT was more frequent in infants vs older children (χ2 = 5.9 [1 df], P = .01). Unstable SVT was present in 13 episodes and was treated with adenosine and antiarrhythmics. Synchronized cardioversion was performed on 3 patients, 2 patients with unstable SVT, and 1 with refractory SVT. CONCLUSION In children with SVT, young age is associated with decreased response to the first dose of adenosine and increased odds of adenosine-refractory SVT. In the treatment of unstable SVT, medical management with various antiarrhythmics before cardioversion may have a role in a subset of patients. Synchronized cardioversion rarely is performed for acute SVT.
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Affiliation(s)
- Jonathan Lewis
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Gaurav Arora
- Department of Pediatrics, Division of Cardiology, University of Pittsburgh, Pittsburgh, PA
| | - Dana L Tudorascu
- Center for Research on Healthcare, University of Pittsburgh, Pittsburgh, PA
| | - Robert W Hickey
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Richard A Saladino
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Mioara D Manole
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh, Pittsburgh, PA.
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Johnson TJ, Hickey RW, Switzer GE, Miller E, Winger DG, Nguyen M, Saladino RA, Hausmann LRM. The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias. Acad Emerg Med 2016; 23:297-305. [PMID: 26763939 DOI: 10.1111/acem.12901] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 10/09/2015] [Accepted: 10/17/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias. METHODS This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores. RESULTS Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21). CONCLUSIONS While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.
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Affiliation(s)
- Tiffani J. Johnson
- Division of Pediatric Emergency Medicine; PolicyLab, and Center for Perinatal and Pediatric Health Disparities Research; Children's Hospital of Philadelphia, and the Department of Pediatrics; University of Pennsylvania School of Medicine; Philadelphia PA
| | - Robert W. Hickey
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Galen E. Switzer
- Division of General Internal Medicine; Department of Medicine; University of Pittsburgh; Pittsburgh PA
- Veterans Affairs Pittsburgh Healthcare System; Center for Health Equity Research and Promotion; Pittsburgh PA
| | - Elizabeth Miller
- Division of Adolescent and Young Adult Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Daniel G. Winger
- Clinical and Translational Science Institute; University of Pittsburgh; Pittsburgh PA
| | - Margaret Nguyen
- Department of Emergency Medicine; Rady Children's Hospital San Diego; San Diego CA
| | - Richard A. Saladino
- Division of Pediatric Emergency Medicine; Department of Pediatrics; University of Pittsburgh; Pittsburgh PA
| | - Leslie R. M. Hausmann
- Division of General Internal Medicine; Department of Medicine; University of Pittsburgh; Pittsburgh PA
- Veterans Affairs Pittsburgh Healthcare System; Center for Health Equity Research and Promotion; Pittsburgh PA
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Liu H, Li W, Rose ME, Hickey RW, Chen J, Uechi GT, Balasubramani M, Day BW, Patel KV, Graham SH. The point mutation UCH-L1 C152A protects primary neurons against cyclopentenone prostaglandin-induced cytotoxicity: implications for post-ischemic neuronal injury. Cell Death Dis 2015; 6:e1966. [PMID: 26539913 PMCID: PMC4670930 DOI: 10.1038/cddis.2015.323] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 09/21/2015] [Accepted: 09/30/2015] [Indexed: 02/08/2023]
Abstract
Cyclopentenone prostaglandins (CyPGs), such as 15-deoxy-Δ12,14-prostaglandin J2 (15dPGJ2), are reactive prostaglandin metabolites exerting a variety of biological effects. CyPGs are produced in ischemic brain and disrupt the ubiquitin-proteasome system (UPS). Ubiquitin-C-terminal hydrolase L1 (UCH-L1) is a brain-specific deubiquitinating enzyme that has been linked to neurodegenerative diseases. Using tandem mass spectrometry (MS) analyses, we found that the C152 site of UCH-L1 is adducted by CyPGs. Mutation of C152 to alanine (C152A) inhibited CyPG modification and conserved recombinant UCH-L1 protein hydrolase activity after 15dPGJ2 treatment. A knock-in (KI) mouse expressing the UCH-L1 C152A mutation was constructed with the bacterial artificial chromosome (BAC) technique. Brain expression and distribution of UCH-L1 in the KI mouse was similar to that of wild type (WT) as determined by western blotting. Primary cortical neurons derived from KI mice were resistant to 15dPGJ2 cytotoxicity compared with neurons from WT mice as detected by the WST-1 cell viability assay and caspase-3 and poly ADP ribose polymerase (PARP) cleavage. This protective effect was accompanied with significantly less ubiquitinated protein accumulation and aggregation as well as less UCH-L1 aggregation in C152A KI primary neurons after 15dPGJ2 treatment. Additionally, 15dPGJ2-induced axonal injury was also significantly attenuated in KI neurons as compared with WT. Taken together, these studies indicate that UCH-L1 function is important in hypoxic neuronal death, and the C152 site of UCH-L1 has a significant role in neuronal survival after hypoxic/ischemic injury.
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Affiliation(s)
- H Liu
- Geriatric Research Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - W Li
- Geriatric Research Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - M E Rose
- Geriatric Research Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - R W Hickey
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J Chen
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - G T Uechi
- Genomics and Proteomics Core Laboratories, University of Pittsburgh, Pittsburgh, PA, USA
| | - M Balasubramani
- Genomics and Proteomics Core Laboratories, University of Pittsburgh, Pittsburgh, PA, USA
| | - B W Day
- Genomics and Proteomics Core Laboratories, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - K V Patel
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - S H Graham
- Geriatric Research Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt ÉW, Schexnayder SM, Samson RA. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015; 132:S526-42. [PMID: 26473000 PMCID: PMC6191296 DOI: 10.1161/cir.0000000000000266] [Citation(s) in RCA: 345] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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40
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de Caen AR, Berg MD, Chameides L, Gooden CK, Hickey RW, Scott HF, Sutton RM, Tijssen JA, Topjian A, van der Jagt ÉW, Schexnayder SM, Samson RA. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (Reprint). Pediatrics 2015; 136 Suppl 2:S176-95. [PMID: 26471384 DOI: 10.1542/peds.2015-3373f] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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41
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Liu H, Chen J, Li W, Rose ME, Shinde SN, Balasubramani M, Uechi GT, Mutus B, Graham SH, Hickey RW. Protein disulfide isomerase as a novel target for cyclopentenone prostaglandins: implications for hypoxic ischemic injury. FEBS J 2015; 282:2045-59. [PMID: 25754985 DOI: 10.1111/febs.13259] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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: 07/25/2014] [Revised: 02/10/2015] [Accepted: 03/05/2015] [Indexed: 01/02/2023]
Abstract
Cyclooxygenase-2 (COX-2) is an important contributor to ischemic brain injury. Identification of the downstream mediators of COX-2 toxicity may allow the development of targeted therapies. Of particular interest is the cyclopentenone family of prostaglandin metabolites. Cyclopentenone prostaglandins (CyPGs) are highly reactive molecules that form covalent bonds with cellular thiols. Protein disulfide isomerase (PDI) is an important molecule for the restoration of denatured proteins following ischemia. Because PDI has several thiols, including thiols within the active thioredoxin-like domain, we hypothesized that PDI is a target of CyPGs and that CyPG binding of PDI is detrimental. CyPG-PDI binding was detected in vitro via immunoprecipitation and MS. CyPG-PDI binding decreased PDI enzymatic activity in recombinant PDI treated with CyPG, and PDI immunoprecipitated from neuronal culture treated with CyPG or anoxia. Toxic effects of binding were demonstrated in experiments showing that: (a) pharmacologic inhibition of PDI increased cell death in anoxic neurons, (b) PDI overexpression protected neurons exposed to anoxia and SH-SY5Y cells exposed to CyPG, and (c) PDI overexpression in SH-SY5Y cells attenuated ubiquitination of proteins and decreased activation of pro-apoptotic caspases. In conclusion, CyPG production and subsequent binding of PDI is a novel and potentially important mechanism of ischemic brain injury. We show that CyPGs bind to PDI, cyclopentenones inhibit PDI activity, and CyPG-PDI binding is associated with increased neuronal susceptibility to anoxia. Additional studies are necessary to determine the relative role of CyPG-dependent inhibition of PDI activity in ischemia and other neurodegenerative disorders.
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Affiliation(s)
- Hao Liu
- Geriatric Research Education and Clinical Center, V.A. Pittsburgh Healthcare System, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, PA, USA
| | - Jie Chen
- Department of Neurology, University of Pittsburgh School of Medicine, PA, USA.,Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, PA, USA
| | - Wenjin Li
- Geriatric Research Education and Clinical Center, V.A. Pittsburgh Healthcare System, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, PA, USA
| | - Marie E Rose
- Geriatric Research Education and Clinical Center, V.A. Pittsburgh Healthcare System, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, PA, USA
| | - Sunita N Shinde
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, PA, USA
| | | | - Guy T Uechi
- Biomedical Mass Spectrometry Center, University of Pittsburgh, PA, USA
| | - Bülent Mutus
- Department of Chemistry & Biochemistry, University of Windsor, ON, Canada
| | - Steven H Graham
- Geriatric Research Education and Clinical Center, V.A. Pittsburgh Healthcare System, PA, USA.,Department of Neurology, University of Pittsburgh School of Medicine, PA, USA
| | - Robert W Hickey
- Department of Pediatrics, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, PA, USA
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Affiliation(s)
- Jennifer R Marin
- From the Departments of Pediatrics (J.R.M., N.S., S.G.D., R.W.H., A.H.) and Emergency Medicine (J.R.M.), University of Pittsburgh, Pittsburgh
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Tress EE, Clark RSB, Foley LM, Alexander H, Hickey RW, Drabek T, Kochanek PM, Manole MD. Blood brain barrier is impermeable to solutes and permeable to water after experimental pediatric cardiac arrest. Neurosci Lett 2014; 578:17-21. [PMID: 24937271 DOI: 10.1016/j.neulet.2014.06.020] [Citation(s) in RCA: 21] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Revised: 05/20/2014] [Accepted: 06/07/2014] [Indexed: 01/04/2023]
Abstract
Pediatric asphyxial cardiac arrest (CA) results in unfavorable neurological outcome in most survivors. Development of neuroprotective therapies is contingent upon understanding the permeability of intravenously delivered medications through the blood brain barrier (BBB). In a model of pediatric CA we sought to characterize BBB permeability to small and large molecular weight substances. Additionally, we measured the percent brain water after CA. Asphyxia of 9 min was induced in 16-18 day-old rats. The rats were resuscitated and the BBB permeability to small (sodium fluorescein and gadoteridol) and large (immunoglobulin G, IgG) molecules was assessed at 1, 4, and 24 h after asphyxial CA or sham surgery. Percent brain water was measured post-CA and in shams using wet-to-dry brain weight. Fluorescence, gadoteridol uptake, or IgG staining at 1, 4h and over the entire 24 h post-CA did not differ from shams, suggesting absence of BBB permeability to these solutes. Cerebral water content was increased at 3h post-CA vs. sham. In conclusion, after 9 min of asphyxial CA there is no BBB permeability over 24h to conventional small or large molecule tracers despite the fact that cerebral water content is increased early post-CA indicating the development of brain edema. Evaluation of novel therapies targeting neuronal death after pediatric CA should include their capacity to cross the BBB.
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Affiliation(s)
- Erika E Tress
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Robert S B Clark
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh, Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Lesley M Foley
- Carnegie Mellon University, NMR Center for Biomedical Research, 4400 Fifth Avenue, Pittsburgh, PA 15213, USA.
| | - Henry Alexander
- University of Pittsburgh, Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Robert W Hickey
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Tomas Drabek
- University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh Department of Anesthesiology, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Patrick M Kochanek
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh, Critical Care Medicine, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
| | - Mioara D Manole
- University of Pittsburgh, Department of Pediatrics, 4401 Penn Avenue, Pittsburgh, PA 15224, USA; University of Pittsburgh, Safar Center for Resuscitation Research, 3434 Fifth Avenue, Pittsburgh, PA 15260, USA.
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Liu H, Li W, Rose ME, Pascoe JL, Miller TM, Ahmad M, Poloyac SM, Hickey RW, Graham SH. Prostaglandin D2 toxicity in primary neurons is mediated through its bioactive cyclopentenone metabolites. Neurotoxicology 2013; 39:35-44. [PMID: 23973622 DOI: 10.1016/j.neuro.2013.08.001] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [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: 03/05/2013] [Revised: 08/01/2013] [Accepted: 08/02/2013] [Indexed: 11/19/2022]
Abstract
Prostaglandin D2 (PGD2) is the most abundant prostaglandin in brain but its effect on neuronal cell death is complex and not completely understood. PGD2 may modulate neuronal cell death via activation of DP receptors or its metabolism to the cyclopentenone prostaglandins (CyPGs) PGJ2, Δ(12)-PGJ2 and 15-deoxy-Δ(12,14)-PGJ2, inducing cell death independently of prostaglandin receptors. This study aims to elucidate the effect of PGD2 on neuronal cell death and its underlying mechanisms. PGD2 dose-dependently induced cell death in rat primary neuron-enriched cultures in concentrations of ≥10μM, and this effect was not reversed by treatment with either DP1 or DP2 receptor antagonists. Antioxidants N-acetylcysteine (NAC) and glutathione which contain sulfhydryl groups that can bind to CyPGs, but not ascorbate or tocopherol, attenuated PGD2-induced cell death. Conversion of PGD2 to CyPGs was detected in neuronal culture medium; treatment with these CyPG metabolites alone exhibited effects similar to those of PGD2, including apoptotic neuronal cell death and accumulation of ubiquitinated proteins. Disruption of lipocalin-type prostaglandin D synthase (L-PGDS) protected neurons against hypoxia. These results support the hypothesis that PGD2 elicits its cytotoxic effects through its bioactive CyPG metabolites rather than DP receptor activation in primary neuronal culture.
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Affiliation(s)
- Hao Liu
- Geriatric Research Education and Clinical Center, V.A. Pittsburgh Healthcare System, 7180 Highland Drive, Pittsburgh, PA 15206, USA; Department of Neurology, University of Pittsburgh School of Medicine, 811 Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
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Liu H, Rose ME, Miller TM, Li W, Shinde SN, Pickrell AM, Poloyac SM, Graham SH, Hickey RW. COX2-derived primary and cyclopentenone prostaglandins are increased after asphyxial cardiac arrest. Brain Res 2013; 1519:71-7. [PMID: 23624225 DOI: 10.1016/j.brainres.2013.04.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2013] [Revised: 04/02/2013] [Accepted: 04/17/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cyclopentenone prostaglandins have been identified as potential neurotoxic agents in the setting of hypoxia-ischemia. Cyclooxygenase-2 (COX-2), the upstream enzyme responsible for prostaglandin production is upregulated following hypoxic-ischemic brain injury. However, the temporal production and concentration of cyclopentenone prostaglandins has not been described following global brain ischemia. METHODS Global brain ischemia was induced in rats by asphyxial cardiac arrest (ACA) followed by resuscitation. Rats were sacrificed between 24h and 7 days following resuscitation and their brains removed. Western blot, immunohistochemistry, and mass spectroscopy were performed. A cohort of rats was pretreated with the COX-2 inhibitor SC58125. RESULTS COX-2 is induced in hippocampus at 24h following ACA. Multiple prostaglandins, including cyclopentenone prostaglandin species, are increased in hippocampus as 24h following ACA. Prostaglandin and cyclopentenone prostaglandin concentrations are returned to baseline at 3 and 7 days post-ischemia. The COX-2 inhibitor SC58125 completely abrogates the post-ischemic increase in prostaglandins and cyclopentenone prostaglandins. CONCLUSIONS Prostaglandins, including cyclopentenone prostaglandins, are increased in ischemic brain, peak at 24h and can be attenuated by the COX-2 inhibitor SC58125. These data establish the presence of potentially neurotoxic cyclopentenone prostaglandins in post-ischemic brains, thus identifying a target and therapeutic window for neuroprotective therapies.
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Affiliation(s)
- Hao Liu
- Geriatric Research Education and Clinical Center, 00-GR-H, VA Pittsburgh Healthcare, United States
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Liu H, Li W, Ahmad M, Rose ME, Miller TM, Yu M, Chen J, Pascoe JL, Poloyac SM, Hickey RW, Graham SH. Increased generation of cyclopentenone prostaglandins after brain ischemia and their role in aggregation of ubiquitinated proteins in neurons. Neurotox Res 2013; 24:191-204. [PMID: 23355003 DOI: 10.1007/s12640-013-9377-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [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: 11/06/2012] [Revised: 01/04/2013] [Accepted: 01/08/2013] [Indexed: 11/26/2022]
Abstract
The cyclopentenone prostaglandin (CyPG) J₂ series, including prostaglandin J₂ (PGJ₂), Δ¹²-PGJ₂, and 15-deoxy-∆¹²,¹⁴-prostaglandin J₂ (15d-PGJ₂), are active metabolites of PGD₂, exerting multiple effects on neuronal function. However, the physiologic relevance of these effects remains uncertain as brain concentrations of CyPGs have not been precisely determined. In this study, we found that free PGD₂ and the J₂ series CyPGs (PGJ₂, Δ¹²-PGJ₂, and 15d-PGJ₂) were increased in post-ischemic rat brain as detected by UPLC-MS/MS with 15d-PGJ₂ being the most abundant CyPG. These increases were attenuated by pre-treating with the cyclooxygenase (COX) inhibitor piroxicam. Next, effects of chronic exposure to 15d-PGJ₂ were examined by treating primary neurons with 15d-PGJ₂, CAY10410 (a 15d-PGJ₂ analog lacking the cyclopentenone ring structure), or vehicle for 24 to 96 h. Because we found that the concentration of free 15d-PGJ₂ decreased rapidly in cell culture medium, freshly prepared medium containing 15d-PGJ₂, CAY10410, or vehicle was changed twice daily to maintain steady extracellular concentrations. Incubation with 2.5 μM 15d-PGJ₂, but not CAY10410, increased the neuronal cell death without the induction of caspase-3 or PARP cleavage, consistent with a primarily necrotic mechanism for 15d-PGJ₂-induced cell death which was further supported by TUNEL assay results. Ubiquitinated protein accumulation and aggregation was observed after 96 h 15d-PGJ₂ incubation, accompanied by compromised 20S proteasome activity. Unlike another proteasome inhibitor, MG132, 15d-PGJ₂ treatment did not activate autophagy or induce aggresome formation. Therefore, the cumulative cytotoxic effects of increased generation of CyPGs after stroke may contribute to delayed post-ischemic neuronal injury.
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Affiliation(s)
- Hao Liu
- Geriatric Research Education and Clinical Center 00-GR-H, V.A. Pittsburgh Healthcare, 7180 Highland Drive, Pittsburgh, PA 15206, USA
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Liu H, Sarnaik SM, Manole MD, Chen Y, Shinde SN, Li W, Rose M, Alexander H, Chen J, Clark RSB, Graham SH, Hickey RW. Increased cytochrome c in rat cerebrospinal fluid after cardiac arrest and its effects on hypoxic neuronal survival. Resuscitation 2012; 83:1491-6. [PMID: 22554683 DOI: 10.1016/j.resuscitation.2012.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [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: 11/23/2011] [Revised: 03/27/2012] [Accepted: 04/16/2012] [Indexed: 11/17/2022]
Abstract
Cerebrospinal fluid (CSF) proteins may be useful biomarkers of neuronal death and ultimate prognosis after hypoxic-ischemic brain injury. Cytochrome c has been identified in the CSF of children following traumatic brain injury. Cytochrome c is required for cellular respiration but it is also a central component of the intrinsic pathway of apoptosis. Thus, in addition to serving as a biomarker, cytochrome c release into CSF may have an effect upon survival of adjacent neurons. In this study, we use Western blot and ELISA to show that cytochrome c is elevated in CSF obtained from pediatric rats following resuscitation from cardiac arrest. Using biotinylated human cytochrome c in culture media we show that cytochrome c crosses the cell membrane and is incorporated into mitochondria of neurons exposed to anoxia. Lastly, we show that addition of human cytochrome c to primary neuronal culture exposed to anoxia improves survival. To our knowledge, this is the first study to show cytochrome c is elevated in CSF following hypoxic ischemic brain injury. Results from primary neuronal culture suggest that extracellular cytochrome c is able to cross the cell membrane of injured neurons, incorporate into mitochondria, and promote survival following anoxia.
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Affiliation(s)
- Hao Liu
- Geriatric Research Educational and Clinical Center, V.A. Pittsburgh Healthcare Center, PA, USA
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de Caen AR, Kleinman ME, Chameides L, Atkins DL, Berg RA, Berg MD, Bhanji F, Biarent D, Bingham R, Coovadia AH, Hazinski MF, Hickey RW, Nadkarni VM, Reis AG, Rodriguez-Nunez A, Tibballs J, Zaritsky AL, Zideman D. Part 10: Paediatric basic and advanced life support: 2010 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations. Resuscitation 2011; 81 Suppl 1:e213-59. [PMID: 20956041 DOI: 10.1016/j.resuscitation.2010.08.028] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Allan R de Caen
- Stollery Children's Hospital, University of Alberta, Canada.
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Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, Samson RA, Kattwinkel J, Berg RA, Bhanji F, Cave DM, Jauch EC, Kudenchuk PJ, Neumar RW, Peberdy MA, Perlman JM, Sinz E, Travers AH, Berg MD, Billi JE, Eigel B, Hickey RW, Kleinman ME, Link MS, Morrison LJ, O'Connor RE, Shuster M, Callaway CW, Cucchiara B, Ferguson JD, Rea TD, Vanden Hoek TL. Part 1: Executive Summary. Circulation 2010; 122:S640-56. [PMID: 20956217 DOI: 10.1161/circulationaha.110.970889] [Citation(s) in RCA: 552] [Impact Index Per Article: 39.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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50
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Kleinman ME, Chameides L, Schexnayder SM, Samson RA, Hazinski MF, Atkins DL, Berg MD, de Caen AR, Fink EL, Freid EB, Hickey RW, Marino BS, Nadkarni VM, Proctor LT, Qureshi FA, Sartorelli K, Topjian A, van der Jagt EW, Zaritsky AL. Part 14: Pediatric Advanced Life Support. Circulation 2010; 122:S876-908. [DOI: 10.1161/circulationaha.110.971101] [Citation(s) in RCA: 473] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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