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Martin NG, Defres S, Willis L, Beckley R, Hardwick H, Coxon A, Kadambari S, Yu LM, Liu X, Galal U, Conlin K, Griffiths MJ, Kneen R, Nadel S, Heath PT, Kelly DE, Solomon T, Sadarangani M, Pollard AJ. Paediatric meningitis in the conjugate vaccine era and a novel clinical decision model to predict bacterial aetiology. J Infect 2024; 88:106145. [PMID: 38552719 DOI: 10.1016/j.jinf.2024.106145] [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] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/13/2024] [Accepted: 03/22/2024] [Indexed: 04/16/2024]
Abstract
OBJECTIVES The aims of this study were to assess aetiology and clinical characteristics in childhood meningitis, and develop clinical decision rules to distinguish bacterial meningitis from other similar clinical syndromes. METHODS Children aged <16 years hospitalised with suspected meningitis/encephalitis were included, and prospectively recruited at 31 UK hospitals. Meningitis was defined as identification of bacteria/viruses from cerebrospinal fluid (CSF) and/or a raised CSF white blood cell count. New clinical decision rules were developed to distinguish bacterial from viral meningitis and those of alternative aetiology. RESULTS The cohort included 3002 children (median age 2·4 months); 1101/3002 (36·7%) had meningitis, including 180 bacterial, 423 viral and 280 with no pathogen identified. Enterovirus was the most common pathogen in those aged <6 months and 10-16 years, with Neisseria meningitidis and/or Streptococcus pneumoniae commonest at age 6 months to 9 years. The Bacterial Meningitis Score had a negative predictive value of 95·3%. We developed two clinical decision rules, that could be used either before (sensitivity 82%, specificity 71%) or after lumbar puncture (sensitivity 84%, specificity 93%), to determine risk of bacterial meningitis. CONCLUSIONS Bacterial meningitis comprised 6% of children with suspected meningitis/encephalitis. Our clinical decision rules provide potential novel approaches to assist with identifying children with bacterial meningitis. FUNDING This study was funded by the Meningitis Research Foundation, Pfizer and the NIHR Programme Grants for Applied Research.
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Affiliation(s)
- N G Martin
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK; Department of Paediatrics, University of Otago Christchurch, 2 Riccarton Avenue, Christchurch Central City, Christchurch 8011, New Zealand
| | - S Defres
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - L Willis
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - R Beckley
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - H Hardwick
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK
| | - A Coxon
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - S Kadambari
- Department of Paediatric Infectious Diseases, Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; Infection, Immunity & Inflammation Department, University College London, Great Ormond Street Institute of Child Health, 30 Guilford St, London WC1N 1EH, UK
| | - L-M Yu
- Nuffield Department of Primary Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Rd, Oxford OX2 6GG, UK
| | - X Liu
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - U Galal
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - K Conlin
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - M J Griffiths
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK; Department of Neurology, Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool L14 5AB, UK
| | - R Kneen
- Department of Neurology, Alder Hey Children's NHS Trust, E Prescot Rd, Liverpool L14 5AB, UK
| | - S Nadel
- Department of Paediatrics, St. Mary's Hospital, Praed St, London W2 1NY, UK
| | - P T Heath
- Centre for Neonatal and Paediatric Infection & Vaccine Institute, St. George's, University of London, Cranmer Terrace, London SW17 0RE, UK
| | - D E Kelly
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
| | - T Solomon
- Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool L69 3BX, UK; Department of Neurology, Walton Centre NHS Foundation Trust, Lower Ln, Fazakerley, Liverpool L9 7LJ, UK
| | - M Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, 950 West 28th Ave, Vancouver, BC V5Z 4H4, Canada; Department of Pediatrics, University of British Columbia, 4480 Oak Street, Vancouver, BC V5Z 4H4, Canada.
| | - A J Pollard
- Department of Paediatrics, University of Oxford and the Oxford University Hospitals NHS Foundation Trust, Level 2, Children's Hospital, John Radcliffe Hospital, Headington, Oxford OX3 9DU, UK
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Nadel S, Lightstone L, Moshal K, Taylor S, Sorene E. Duty and advocacy for Palestine: Jewish doctors' response. Lancet 2024; 403:1541-1542. [PMID: 38608687 DOI: 10.1016/s0140-6736(24)00240-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 02/06/2024] [Indexed: 04/14/2024]
Affiliation(s)
- Simon Nadel
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London W2 1NY, UK.
| | | | - Karyn Moshal
- Great Ormond Street Hospital for Children NHS Trust, London, UK
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Schlapbach LJ, Watson RS, Sorce LR, Argent AC, Menon K, Hall MW, Akech S, Albers DJ, Alpern ER, Balamuth F, Bembea M, Biban P, Carrol ED, Chiotos K, Chisti MJ, DeWitt PE, Evans I, Flauzino de Oliveira C, Horvat CM, Inwald D, Ishimine P, Jaramillo-Bustamante JC, Levin M, Lodha R, Martin B, Nadel S, Nakagawa S, Peters MJ, Randolph AG, Ranjit S, Rebull MN, Russell S, Scott HF, de Souza DC, Tissieres P, Weiss SL, Wiens MO, Wynn JL, Kissoon N, Zimmerman JJ, Sanchez-Pinto LN, Bennett TD. International Consensus Criteria for Pediatric Sepsis and Septic Shock. JAMA 2024; 331:665-674. [PMID: 38245889 PMCID: PMC10900966 DOI: 10.1001/jama.2024.0179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
Importance Sepsis is a leading cause of death among children worldwide. Current pediatric-specific criteria for sepsis were published in 2005 based on expert opinion. In 2016, the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction caused by a dysregulated host response to infection, but it excluded children. Objective To update and evaluate criteria for sepsis and septic shock in children. Evidence Review The Society of Critical Care Medicine (SCCM) convened a task force of 35 pediatric experts in critical care, emergency medicine, infectious diseases, general pediatrics, nursing, public health, and neonatology from 6 continents. Using evidence from an international survey, systematic review and meta-analysis, and a new organ dysfunction score developed based on more than 3 million electronic health record encounters from 10 sites on 4 continents, a modified Delphi consensus process was employed to develop criteria. Findings Based on survey data, most pediatric clinicians used sepsis to refer to infection with life-threatening organ dysfunction, which differed from prior pediatric sepsis criteria that used systemic inflammatory response syndrome (SIRS) criteria, which have poor predictive properties, and included the redundant term, severe sepsis. The SCCM task force recommends that sepsis in children be identified by a Phoenix Sepsis Score of at least 2 points in children with suspected infection, which indicates potentially life-threatening dysfunction of the respiratory, cardiovascular, coagulation, and/or neurological systems. Children with a Phoenix Sepsis Score of at least 2 points had in-hospital mortality of 7.1% in higher-resource settings and 28.5% in lower-resource settings, more than 8 times that of children with suspected infection not meeting these criteria. Mortality was higher in children who had organ dysfunction in at least 1 of 4-respiratory, cardiovascular, coagulation, and/or neurological-organ systems that was not the primary site of infection. Septic shock was defined as children with sepsis who had cardiovascular dysfunction, indicated by at least 1 cardiovascular point in the Phoenix Sepsis Score, which included severe hypotension for age, blood lactate exceeding 5 mmol/L, or need for vasoactive medication. Children with septic shock had an in-hospital mortality rate of 10.8% and 33.5% in higher- and lower-resource settings, respectively. Conclusions and Relevance The Phoenix sepsis criteria for sepsis and septic shock in children were derived and validated by the international SCCM Pediatric Sepsis Definition Task Force using a large international database and survey, systematic review and meta-analysis, and modified Delphi consensus approach. A Phoenix Sepsis Score of at least 2 identified potentially life-threatening organ dysfunction in children younger than 18 years with infection, and its use has the potential to improve clinical care, epidemiological assessment, and research in pediatric sepsis and septic shock around the world.
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Affiliation(s)
- Luregn J. Schlapbach
- Department of Intensive Care and Neonatology, and Children’s Research Center, University Children’s Hospital Zurich, University of Zurich, Zurich, Switzerland
- Child Health Research Centre, University of Queensland, Brisbane, Australia
| | - R. Scott Watson
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew C. Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa
- University of Cape Town, Cape Town, South Africa
| | - Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Canada
- University of Ottawa, Ontario, Canada
| | - Mark W. Hall
- Division of Critical Care Medicine, Nationwide Children’s Hospital, Columbus, Ohio
- The Ohio State University College of Medicine, Columbus, Ohio
| | - Samuel Akech
- Kenya Medical Research Institute (KEMRI)–Wellcome Trust Research Programme, Nairobi, Kenya
| | - David J. Albers
- Departments of Biomedical Informatics, Bioengineering, Biostatistics and Informatics, University of Colorado School of Medicine, Aurora
- Department of Biomedical Informatics, Columbia University, New York, New York
| | - Elizabeth R. Alpern
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Fran Balamuth
- Department of Pediatrics, University of Pennsylvania, Perelman School of Medicine, Philadelphia
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Melania Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Paolo Biban
- Pediatric Intensive Care Unit, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- University of Liverpool, Department of Clinical Infection, Microbiology and Immunology, Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Divisions of Critical Care Medicine and Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Mohammod Jobayer Chisti
- Intensive Care Unit, Dhaka Hospital, Nutrition Research Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Peter E. DeWitt
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Idris Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - Cláudio Flauzino de Oliveira
- AMIB–Associação de Medicina Intensiva Brasileira, São Paulo, Brazil
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
| | - Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, Pennsylvania
| | - David Inwald
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California, San Diego School of Medicine, La Jolla
| | - Juan Camilo Jaramillo-Bustamante
- PICU Hospital General de Medellín “Luz Castro de Gutiérrez” and Hospital Pablo Tobón Uribe, Medellín, Colombia
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network)
| | - Michael Levin
- Section of Paediatric Infectious Diseases, Department of Infectious Diseases, Imperial College London, London, United Kingdom
- Department of Paediatrics, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Rakesh Lodha
- Department of Pediatrics, All India Institute of Medical Sciences, New Delhi, India
| | - Blake Martin
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
- Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, London, United Kingdom
- Imperial College London, London, United Kingdom
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Mark J. Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
- Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, United Kingdom
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Anaesthesia and Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Suchitra Ranjit
- Pediatric Intensive Care Unit, Apollo Children’s Hospital, Chennai, India
| | - Margaret N. Rebull
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Seth Russell
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora
| | - Halden F. Scott
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora
- Emergency Department, Children’s Hospital Colorado, Aurora
| | - Daniela Carla de Souza
- LASI–Latin American Institute of Sepsis, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Universitario of the University of São Paulo, São Paulo, Brazil
- Department of Pediatrics (PICU), Hospital Sírio Libanês, São Paulo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - Scott L. Weiss
- Division of Critical Care, Department of Pediatrics, Nemours Children’s Health, Wilmington, Delaware
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Matthew O. Wiens
- Department of Anesthesiology, Pharmacology and Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Institute for Global Health, BC Children’s Hospital, Vancouver, Canada and Walimu, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Jerry J. Zimmerman
- Department of Pediatrics, University of Washington, Seattle
- Seattle Children’s Research Institute and Pediatric Critical Care, Seattle Children’s, Seattle, Washington
| | - L. Nelson Sanchez-Pinto
- Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
- Department of Pediatrics, Division of Critical Care, and Department of Preventive Medicine, Division of Health & Biomedical Informatics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Tellen D. Bennett
- Departments of Biomedical Informatics and Pediatrics (Division of Critical Care Medicine), University of Colorado School of Medicine and Pediatric Intensive Care Unit, Children’s Hospital Colorado, Aurora
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Swieboda D, Rice TF, Guo Y, Nadel S, Thwaites RS, Openshaw PJM, Holder B, Culley FJ. Natural killer cells and innate lymphoid cells but not NKT cells are mature in their cytokine production at birth. Clin Exp Immunol 2024; 215:1-14. [PMID: 37556759 PMCID: PMC10776247 DOI: 10.1093/cei/uxad094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/02/2023] [Accepted: 08/08/2023] [Indexed: 08/11/2023] Open
Abstract
Early life is a time of increased susceptibility to infectious diseases and development of allergy. Innate lymphocytes are crucial components of the initiation and regulation of immune responses at mucosal surfaces, but functional differences in innate lymphocytes early in life are not fully described. We aimed to characterize the abundance and function of different innate lymphocyte cell populations in cord blood in comparison to that of adults. Blood was collected from adult donors and umbilical vessels at birth. Multicolor flow cytometry panels were used to identify and characterize lymphocyte populations and their capacity to produce hallmark cytokines. Lymphocytes were more abundant in cord blood compared to adults, however, mucosal-associated invariant T cells and natural killer T (NKT)-like cells, were far less abundant. The capacity of NKT-like cells to produce cytokines and their expression of the cytotoxic granule protein granzyme B and the marker of terminal differentiation CD57 were much lower in cord blood than in adults. In contrast, natural killer (NK) cells were as abundant in cord blood as in adults, they could produce IFNγ, and their expression of granzyme B was not significantly different from that of adult NK cells, although CD57 expression was lower. All innate lymphoid cell (ILC) subsets were more abundant in cord blood, and ILC1 and ILC2 were capable of production of IFNγ and IL-13, respectively. In conclusion, different innate lymphoid cells differ in both abundance and function in peripheral blood at birth and with important implications for immunity in early life.
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Affiliation(s)
- Dawid Swieboda
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Thomas F Rice
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Yanping Guo
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Simon Nadel
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Ryan S Thwaites
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Peter J M Openshaw
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Beth Holder
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
| | - Fiona J Culley
- National Heart and Lung Institute, Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, UK
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Miranda M, Ray S, Boot E, Inwald D, Meena D, Kumar R, Davies P, Rivero-Bosch M, Sturgess P, Weeks C, Holliday K, Cuevas-Asturias S, Donnelly P, Elsaoudi A, Lillie J, Nadel S, Tibby S, Mitting R. Variation in Early Pediatric Intensive Care Management Strategies and Duration of Invasive Mechanical Ventilation for Acute Viral Bronchiolitis in the United Kingdom: A Retrospective Multicenter Cohort Study. Pediatr Crit Care Med 2023; 24:1010-1021. [PMID: 37493464 DOI: 10.1097/pcc.0000000000003333] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
OBJECTIVES Management of mechanically ventilated patients with bronchiolitis is not standardized and duration of mechanical ventilation has been shown to vary widely between centers. The aim of this study was to examine practice in a large number of U.K. PICUs with a view to identify if early management choices relating to fluid prescription, sedative agent use, and endotracheal tube (ETT) placement were associated with differences in duration of invasive mechanical ventilation (IMV). DESIGN Retrospective multicenter cohort study. Primary outcome was duration of IMV. A hierarchical gamma generalized linear model was used to test for associations between practice variables (sedative and neuromuscular blocking agents, route of endotracheal intubation at 24 hr and fluid balance at 48 hr) and duration of IMV after adjustment for known confounders. SETTING Thirteen U.K. PICUs. Duration of 2 months between November and December 2019. PATIENTS Three hundred fifty infants receiving IMV for bronchiolitis. Excluded were patients receiving long-term ventilation, extracorporeal life support, or who died before separation from IMV. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After adjustment for confounders, several variables were associated with an increase in the geometric mean duration of IMV (expressed as a percentage) including: nasal ETT use, 16% (95% CI, 1-32%); neuromuscular blockade use, 39% (95% CI, 21-61%); and fluid balance at 48 hr, 13% per 100 mL/kg positive fluid balance (95% CI, -1% to 28%). The association of sedative use varied with class of agent. The use of an alpha-2 agonist alone was associated with a reduction in duration of IMV by 19% in relation to no sedative agent (95% CI, -31 to -5%), whereas benzodiazepine uses alone or with alpha-2 agonist in combination were similar to using neither agent. CONCLUSIONS Early management strategies for bronchiolitis were associated with the duration of IMV across U.K. centers after adjustment for confounders. Future work should prospectively assess the impact of fluid restriction, route of endotracheal intubation, and alpha-2 agonist use on duration of IMV in infants with bronchiolitis, with the aim of reducing seasonal bed pressure.
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Affiliation(s)
- Mariana Miranda
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Samiran Ray
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
- Infection, Immunity and Inflammation Research and Teaching Department, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Elizabeth Boot
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - David Inwald
- Pediatric Intensive Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Daleep Meena
- Pediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Ramesh Kumar
- Pediatric Intensive Care Unit, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Patrick Davies
- Pediatric Intensive Care Unit, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Maria Rivero-Bosch
- Pediatric Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Philippa Sturgess
- Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Charlotte Weeks
- Pediatric Intensive Care Unit, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, United Kingdom
| | - Kathryn Holliday
- Pediatric Intensive Care Unit, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, United Kingdom
| | - Sofia Cuevas-Asturias
- Pediatric Intensive Care Unit, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Peter Donnelly
- Pediatric Intensive Care Unit, The Royal Hospital For Children, NHS Greater Glasgow and Clyde, Glasgow, United Kingdom
| | - Ahmed Elsaoudi
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Jon Lillie
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Simon Nadel
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Centre for Paediatrics and Child Health, Imperial College, London, United Kingdom
| | - Shane Tibby
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Rebecca Mitting
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
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Almossawi O, Friend A, Palla L, Feltbower RG, Sardo-Infiri S, O’Brien S, Harron K, Nadel S, Saunders P, De Stavola B. Is there a sex difference in mortality rates in paediatric intensive care units?: a systematic review. Front Pediatr 2023; 11:1225684. [PMID: 37876523 PMCID: PMC10591324 DOI: 10.3389/fped.2023.1225684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/30/2023] [Indexed: 10/26/2023] Open
Abstract
Introduction Mortality rates in infancy and childhood are lower in females than males. However, for children admitted to Paediatric Intensive Care Units (PICU), mortality has been reported to be lower in males, although males have higher admission rates. This female mortality excess for the subgroup of children admitted in intensive care is not well understood. To address this, we carried out a systematic literature review to summarise the available evidence. Our review studies the differences in mortality between males and females aged 0 to <18 years, while in a PICU, to examine whether there was a clear difference (in either direction) in PICU mortality between the two sexes, and, if present, to describe the magnitude and direction of this difference. Methods Any studies that directly or indirectly reported the rates of mortality in children admitted to intensive care by sex were eligible for inclusion. The search strings were based on terms related to the population (those admitted into a paediatric intensive care unit), the exposure (sex), and the outcome (mortality). We used the search databases MEDLINE, Embase, and Web of Science as these cover relevant clinical publications. We assessed the reliability of included studies using a modified version of the risk of bias in observational studies of exposures (ROBINS-E) tool. We considered estimating a pooled effect if there were at least three studies with similar populations, periods of follow-up while in PICU, and adjustment variables. Results We identified 124 studies of which 114 reported counts of deaths by males and females which gave a population of 278,274 children for analysis, involving 121,800 (44%) females and 156,474 males (56%). The number of deaths and mortality rate for females were 5,614 (4.61%), and for males 6,828 (4.36%). In the pooled analysis, the odds ratio of female to male mortality was 1.06 [1.01 to 1.11] for the fixed effect model, and 1.10 [1.00 to 1.21] for the random effects model. Discussion Overall, males have a higher admission rate to PCU, and potentially lower overall mortality in PICU than females. Systematic Review Registration www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=203009, identifier (CRD42020203009).
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Affiliation(s)
- Ofran Almossawi
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Amanda Friend
- Department of Paediatric Oncology, Birmingham Children's Hospital, Birmingham, United Kingdom
| | - Luigi Palla
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy
- Department of Global Health, Nagasaki University Institute of Tropical Medicine, Nagasaki, Japan
| | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Sofia Sardo-Infiri
- Department of Medical Statistics, The Royal Marsden Hospital, London, United Kingdom
| | - Scott O’Brien
- Research Fellow, Imperial Charity (NIHR/BRC), St. Mary's Hospital, London, United Kingdom
| | - Katie Harron
- Institute of Child Health, University College London, London, United Kingdom
| | - Simon Nadel
- Paediatric Intensive Care Unit, St. Mary's Hospital, London, United Kingdom
| | | | - Bianca De Stavola
- Institute of Child Health, University College London, London, United Kingdom
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Miranda M, Nadel S. Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations. Curr Pediatr Rep 2023; 11:29-39. [PMID: 37252329 PMCID: PMC10169116 DOI: 10.1007/s40124-023-00286-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/31/2023]
Abstract
Purpose of Review Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement. Recent Findings Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Summary Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.
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Affiliation(s)
- Mariana Miranda
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Simon Nadel
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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8
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Di Nardo M, Ahmad AH, Merli P, Zinter MS, Lehman LE, Rowan CM, Steiner ME, Hingorani S, Angelo JR, Abdel-Azim H, Khazal SJ, Shoberu B, McArthur J, Bajwa R, Ghafoor S, Shah SH, Sandhu H, Moody K, Brown BD, Mireles ME, Steppan D, Olson T, Raman L, Bridges B, Duncan CN, Choi SW, Swinford R, Paden M, Fortenberry JD, Peek G, Tissieres P, De Luca D, Locatelli F, Corbacioglu S, Kneyber M, Franceschini A, Nadel S, Kumpf M, Loreti A, Wösten-Van Asperen R, Gawronski O, Brierley J, MacLaren G, Mahadeo KM. Extracorporeal membrane oxygenation in children receiving haematopoietic cell transplantation and immune effector cell therapy: an international and multidisciplinary consensus statement. Lancet Child Adolesc Health 2022; 6:116-128. [PMID: 34895512 PMCID: PMC9372796 DOI: 10.1016/s2352-4642(21)00336-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023]
Abstract
Use of extracorporeal membrane oxygenation (ECMO) in children receiving haematopoietic cell transplantation (HCT) and immune effector cell therapy is controversial and evidence-based guidelines have not been established. Remarkable advancements in HCT and immune effector cell therapies have changed expectations around reversibility of organ dysfunction and survival for affected patients. Herein, members of the Extracorporeal Life Support Organization (ELSO), Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (HCT and cancer immunotherapy subgroup), the Pediatric Diseases Working Party of the European Society for Blood and Marrow Transplantation (EBMT), the supportive care committee of the Pediatric Transplantation and Cellular Therapy Consortium (PTCTC), and the Pediatric Intensive Care Oncology Kids in Europe Research (POKER) group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) provide consensus recommendations on the use of ECMO in children receiving HCT and immune effector cell therapy. These are the first international, multidisciplinary consensus-based recommendations on the use of ECMO in this patient population. This Review provides a clinical decision support tool for paediatric haematologists, oncologists, and critical care physicians during the difficult decision-making process of ECMO candidacy and management. These recommendations can represent a base for future research studies focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Ali H Ahmad
- Department of Pediatrics, Pediatric Critical Care, Houston, TX, USA
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matthew S Zinter
- Department of Pediatrics, Divisions of Critical Care and Bone Marrow Transplantation, University of California, San Francisco, CA, USA
| | - Leslie E Lehman
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Courtney M Rowan
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, Division of Nephrology, University of Washington School of Medicine, and the Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Transplantation and Cell Therapy Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sajad J Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Basirat Shoberu
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer McArthur
- Division of Critical Care Medicine, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Rajinder Bajwa
- Department of Pediatrics, Division of Blood and Marrow Transplantation, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Saad Ghafoor
- Division of Critical Care Medicine, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Samir H Shah
- Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hitesh Sandhu
- Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karen Moody
- CARTOX Program, and Department of Pediatrics, Supportive Care, Houston, TX, USA
| | - Brandon D Brown
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Diana Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Taylor Olson
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Lakshmi Raman
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brian Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christine N Duncan
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Sung Won Choi
- University of Michigan, Rogel Cancer Center, Ann Arbor, MI, USA; Department of Pediatrics, Ann Arbor, MI, USA
| | - Rita Swinford
- Department of Pediatrics, Division of Pediatric Nephrology, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Matt Paden
- Pediatric Critical Care, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, GA, USA
| | - James D Fortenberry
- Pediatric Critical Care, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, GA, USA
| | - Giles Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Pierre Tissieres
- Division of Pediatric Intensive Care and Neonatal Medicine, Paris South University Hospital, Le Kremlin-Bicetre, France; Institute of Integrative Biology of the Cell, CNRS, CEA, Univ. Paris Sud, Paris Saclay University, Paris, France
| | - Daniele De Luca
- Division of Pediatrics, Transportation and Neonatal Critical Care Medicine, APHP, Paris Saclay University Hospital, "A.Beclere" Medical Center and Physiopathology and Therapeutic Innovation Unit-INSERM-U999, Paris Saclay University, Paris, France
| | - Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Martin Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital Groningen, Groningen, Netherlands; Critical Care, Anesthesiology, Peri-Operative and Emergency Medicine (CAPE), University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Alessio Franceschini
- Department of Cardiosurgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simon Nadel
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Matthias Kumpf
- Interdisciplinary Pediatric Intensive Care Unit, Universitäetsklinikum Tuebingen, Tuebingen, Germany
| | - Alessandra Loreti
- Medical Library, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roelie Wösten-Van Asperen
- Department of Pediatric Intensive Care, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Joe Brierley
- Department of Pediatric Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - Graeme MacLaren
- Director of Cardiothoracic ICU, National University Health System, Singapore, Singapore; Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Kris M Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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9
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Miranda M, Nadel S. Impact of Inherited Genetic Variants on Critically Ill Septic Children. Pathogens 2022; 11:pathogens11010096. [PMID: 35056044 PMCID: PMC8781648 DOI: 10.3390/pathogens11010096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 01/05/2022] [Accepted: 01/10/2022] [Indexed: 11/16/2022] Open
Abstract
Sepsis remains an important source of morbidity and mortality in children, despite the development of standardized care. In the last decades, there has been an increased interest in genetic and genomic approaches to early recognition and development of treatments to manipulate the host inflammatory response. This review will present a summary of the normal host response to infection and progression to sepsis, followed by highlighting studies with a focus on gene association studies, epigenetics, and genome-wide expression profiling. The susceptibility (or outcome) of sepsis in children has been associated with several polymorphisms of genes broadly involved in inflammation, immunity, and coagulation. More recently, gene expression profiling has been focused on identifying novel biomarkers, pathways and therapeutic targets, and gene expression-based subclassification. Knowledge of a patient’s individual genotype may, in the not-too-remote future, be used to guide tailored treatment for sepsis. However, at present, the impact of genomics remains far from the bedside of critically ill children.
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Affiliation(s)
- Mariana Miranda
- Paediatric Unit, Imperial College Healthcare NHS Trust, London W2 1NY, UK
- Correspondence:
| | - Simon Nadel
- St. Mary’s Hospital, Imperial College Healthcare NHS Trust, and Imperial College, London W2 1NY, UK;
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10
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Menon K, Schlapbach LJ, Akech S, Argent A, Biban P, Carrol ED, Chiotos K, Jobayer Chisti M, Evans IVR, Inwald DP, Ishimine P, Kissoon N, Lodha R, Nadel S, Oliveira CF, Peters M, Sadeghirad B, Scott HF, de Souza DC, Tissieres P, Watson RS, Wiens MO, Wynn JL, Zimmerman JJ, Sorce LR. Criteria for Pediatric Sepsis-A Systematic Review and Meta-Analysis by the Pediatric Sepsis Definition Taskforce. Crit Care Med 2022; 50:21-36. [PMID: 34612847 PMCID: PMC8670345 DOI: 10.1097/ccm.0000000000005294] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To determine the associations of demographic, clinical, laboratory, organ dysfunction, and illness severity variable values with: 1) sepsis, severe sepsis, or septic shock in children with infection and 2) multiple organ dysfunction or death in children with sepsis, severe sepsis, or septic shock. DATA SOURCES MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from January 1, 2004, and November 16, 2020. STUDY SELECTION Case-control studies, cohort studies, and randomized controlled trials in children greater than or equal to 37-week-old postconception to 18 years with suspected or confirmed infection, which included the terms "sepsis," "septicemia," or "septic shock" in the title or abstract. DATA EXTRACTION Study characteristics, patient demographics, clinical signs or interventions, laboratory values, organ dysfunction measures, and illness severity scores were extracted from eligible articles. Random-effects meta-analysis was performed. DATA SYNTHESIS One hundred and six studies met eligibility criteria of which 81 were included in the meta-analysis. Sixteen studies (9,629 patients) provided data for the sepsis, severe sepsis, or septic shock outcome and 71 studies (154,674 patients) for the mortality outcome. In children with infection, decreased level of consciousness and higher Pediatric Risk of Mortality scores were associated with sepsis/severe sepsis. In children with sepsis/severe sepsis/septic shock, chronic conditions, oncologic diagnosis, use of vasoactive/inotropic agents, mechanical ventilation, serum lactate, platelet count, fibrinogen, procalcitonin, multi-organ dysfunction syndrome, Pediatric Logistic Organ Dysfunction score, Pediatric Index of Mortality-3, and Pediatric Risk of Mortality score each demonstrated significant and consistent associations with mortality. Pooled mortality rates varied among high-, upper middle-, and lower middle-income countries for patients with sepsis, severe sepsis, and septic shock (p < 0.0001). CONCLUSIONS Strong associations of several markers of organ dysfunction with the outcomes of interest among infected and septic children support their inclusion in the data validation phase of the Pediatric Sepsis Definition Taskforce.
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Affiliation(s)
- Kusum Menon
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
| | - Luregn J. Schlapbach
- Pediatric and Neonatal ICU, University Children`s Hospital Zurich, Zurich, Switzerland, and Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Akech
- KEMRI Wellcome Trust Research Program, Nairobi, Kenya
| | - Andrew Argent
- Department of Paediatrics and Child Health, Red Cross War Memorial Children’s Hospital and University of Cape Town, Cape Town, South Africa
| | - Paolo Biban
- Department of Paediatrics, Verona University Hospital, Verona, Italy
| | - Enitan D. Carrol
- Department of Clinical Infection Microbiology and Immunology, University of Liverpool Institute of Infection, Veterinary and Ecological Sciences, Liverpool, United Kingdom
| | | | | | - Idris V. R. Evans
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, and The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA
| | - David P. Inwald
- Paediatric Intensive Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, La Jolla, CA
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia and British Columbia Children’s Hospital, Vancouver, BC, Canada
| | - Rakesh Lodha
- All India Institute of Medical Sciences, Delhi, India
| | - Simon Nadel
- St. Mary’s Hospital, Imperial College Healthcare NHS Trust, and Imperial College London, London, United Kingdom
| | | | - Mark Peters
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Benham Sadeghirad
- Departments of Anesthesia and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Halden F. Scott
- Departments of Pediatrics and Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Daniela C. de Souza
- Departments of Pediatrics, Hospital Sírio-Libanês and Hospital Universitário da Universidade de São Paulo, São Paolo, Brazil
| | - Pierre Tissieres
- Pediatric Intensive Care, AP-HP Paris Saclay University, Bicêtre Hospital, Le Kremlin-Bicêtre, France
| | - R. Scott Watson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Matthew O. Wiens
- University of British Columbia, Vancouver, BC, Canada
- Mbarara University of Science and Technology, Mbarara, Uganda
| | - James L. Wynn
- Department of Pediatrics, University of Florida, Gainesville, FL
| | - Jerry J. Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
| | - Lauren R. Sorce
- Ann & Robert H. Lurie Children’s Hospital and Department of Pediatrics, Northwestern University Feinberg School of Medicine, Lurie Children’s Pediatric Research & Evidence Synthesis Center (PRECIISE): A JBI Affiliated Group, Chicago, IL
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11
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Abstract
Sepsis is a common, complex condition that requires early recognition and aggressive management to improve outcomes. There has been significant improvement in the management of sepsis and septic shock in the last decade; however, it continues to be a leading cause of mortality, morbidity and burden on healthcare services globally. Several guidelines with evidence-based recommendations for the management of children with septic shock and associated organ dysfunction have been produced with the objective of helping clinicians in various settings to provide standardised high-quality care. This article aims to increase awareness among all clinicians, including those working in emergency departments, general paediatric wards and primary care physicians, about the management of sepsis in children.
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Affiliation(s)
- Niha Peshimam
- Paediatric Intensive Care, St Mary's Hospital, London, UK
| | - Simon Nadel
- Consultant and Adjunct Professor, Paediatric Intensive Care, St Mary's Hospital and Imperial College London, London, W2 1NY, UK
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12
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Esposito S, Abu-Raya B, Bonanni P, Cahn-Sellem F, Flanagan KL, Martinon Torres F, Mejias A, Nadel S, Safadi MAP, Simon A. Coadministration of Anti-Viral Monoclonal Antibodies With Routine Pediatric Vaccines and Implications for Nirsevimab Use: A White Paper. Front Immunol 2021; 12:708939. [PMID: 34456918 PMCID: PMC8386277 DOI: 10.3389/fimmu.2021.708939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/15/2021] [Indexed: 02/01/2023] Open
Abstract
Routine childhood vaccinations are key for the protection of children from a variety of serious and potentially fatal diseases. Current pediatric vaccine schedules mainly cover active vaccines. Active vaccination in infants is a highly effective approach against several infectious diseases; however, thus far, for some important viral pathogens, including respiratory syncytial virus (RSV), vaccine development and license by healthcare authorities have not been accomplished. Nirsevimab is a human-derived, highly potent monoclonal antibody (mAb) with an extended half-life for RSV prophylaxis in all infants. In this manuscript, we consider the potential implications for the introduction of an anti-viral mAb, such as nirsevimab, into the routine pediatric vaccine schedule, as well as considerations for coadministration. Specifically, we present evidence on the general mechanism of action of anti-viral mAbs and experience with palivizumab, the only approved mAb for the prevention of RSV infection in preterm infants, infants with chronic lung disease of prematurity and certain infants with hemodynamically significant heart disease. Palivizumab has been used for over two decades in infants who also receive routine vaccinations without any alerts concerning the safety and efficacy of coadministration. Immunization guidelines (Advisory Committee on Immunization Practices, Joint Committee on Vaccination and Immunization, National Advisory Committee on Immunization, Centers for Disease Control and Prevention, American Academy of Pediatrics, The Association of the Scientific Medical Societies in Germany) support coadministration of palivizumab with routine pediatric vaccines, noting that immunobiologics, such as palivizumab, do not interfere with the immune response to licensed live or inactivated active vaccines. Based on the mechanism of action of the new generation of anti-viral mAbs, such as nirsevimab, which is highly specific targeting viral antigenic sites, it is unlikely that it could interfere with the immune response to other vaccines. Taken together, we anticipate that nirsevimab could be concomitantly administered to infants with routine pediatric vaccines during the same clinic visit.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Bahaa Abu-Raya
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Paolo Bonanni
- Specialization Medical School of Hygiene, Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Katie L. Flanagan
- Tasmanian Vaccine Trial Centre, Launceston General Hospital, Launceston, TAS, Australia
- School of Medicine, University of Tasmania, Launceston, TAS, Australia
- Department of Immunology and Pathology, Monash University, Melbourne, VIC, Australia
- School of Health and Biomedical Science, Royal Melbourne Institute of Technology (RMIT) University, Melbourne, VIC, Australia
| | - Federico Martinon Torres
- Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines and Pediatrics Research Group, Instituto de Investigación Sanitaria de Santiago de Compostela, Universidad de Santiago, Santiago de Compostela, Spain
| | - Asuncion Mejias
- Division of Infectious Diseases, Department of Pediatrics, Center for Vaccines and Immunity Nationwide Children’s Hospital-The Ohio State University College of Medicine, Columbus, OH, United States
- Department of Pharmacology and Pediatrics, Malaga Medical School, Malaga University, Malaga, Spain
| | | | - Marco A. P. Safadi
- Department of Pediatrics, Santa Casa de Sao Paulo School of Medical Sciences, Sao Paulo, Brazil
| | - Arne Simon
- Klinik für Pädiatrische Onkologie und Hämatologie Universitätsklinikum des Saarlandes, Homburg, Germany
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13
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Sinha R, Aramburo A, Deep A, Bould EJ, Buckley HL, Draper ES, Feltbower R, Mitting R, Mahoney S, Alexander J, Playfor S, Chan-Dominy A, Nadel S, Suntharalingam G, Fraser J, Ramnarayan P. Caring for critically ill adults in paediatric intensive care units in England during the COVID-19 pandemic: planning, implementation and lessons for the future. Arch Dis Child 2021; 106:548-557. [PMID: 33509793 PMCID: PMC7844931 DOI: 10.1136/archdischild-2020-320962] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 12/30/2020] [Accepted: 01/14/2021] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To describe the experience of paediatric intensive care units (PICUs) in England that repurposed their units, equipment and staff to care for critically ill adults during the first wave of the COVID-19 pandemic. DESIGN Descriptive study. SETTING Seven PICUs in England. MAIN OUTCOME MEASURES (1) Modelling using historical Paediatric Intensive Care Audit Network data; (2) space, staff, equipment, clinical care, communication and governance considerations during repurposing of PICUs; (3) characteristics, interventions and outcomes of adults cared for in repurposed PICUs. RESULTS Seven English PICUs, accounting for 137 beds, repurposed their space, staff and equipment to admit critically ill adults. Neighbouring PICUs increased their bed capacity to maintain overall bed numbers for children, which was informed by historical data modelling (median 280-307 PICU beds were required in England from March to June). A total of 145 adult patients (median age 50-62 years) were cared for in repurposed PICUs (1553 bed-days). The vast majority of patients had COVID-19 (109/145, 75%); the majority required invasive ventilation (91/109, 85%). Nearly, a third of patients (42/145, 29%) underwent a tracheostomy. Renal replacement therapy was provided in 20/145 (14%) patients. Twenty adults died in PICU (14%). CONCLUSION In a rapid and unprecedented effort during the first wave of the COVID-19 pandemic, seven PICUs in England were repurposed to care for adult patients. The success of this effort was underpinned by extensive local preparation, close collaboration with adult intensivists and careful national planning to safeguard paediatric critical care capacity.
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Affiliation(s)
- Ruchi Sinha
- Department of Paediatric Intensive Care, Division of Women and Children's Services, Imperial College Healthcare NHS Trust, London, UK
| | - Angela Aramburo
- Paediatric Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, London, UK
| | - Emma-Jane Bould
- Paediatric Intensive Care Unit, Barts Health NHS Trust, London, UK
| | | | | | | | - Rebecca Mitting
- Department of Paediatric Intensive Care, Division of Women and Children's Services, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Mahoney
- Paediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - John Alexander
- Paediatric Intensive Care Unit, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | | | - Amy Chan-Dominy
- Paediatric Intensive Care Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Simon Nadel
- Department of Paediatric Intensive Care, Division of Women and Children's Services, Imperial College Healthcare NHS Trust, London, UK
| | - Ganesh Suntharalingam
- Adult Intensive Care Unit, North West London Hospitals NHS Trust, Harrow, UK
- Intensive Care Society, London, UK
| | - James Fraser
- Paediatric Intensive Care Unit, Bristol Royal Hospital for Children, Bristol, UK
- Paediatric Intensive Care Society, London, UK
| | - Padmanabhan Ramnarayan
- Department of Paediatric Intensive Care, Division of Women and Children's Services, Imperial College Healthcare NHS Trust, London, UK
- Paediatric Intensive Care Society, London, UK
- Children's Acute Transport Service, Great Ormond Street Hospital for Children NHS Foundation Trust and NIHR Biomedical Research Centre, London, UK
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14
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Jefferies K, Drysdale SB, Robinson H, Clutterbuck EA, Blackwell L, McGinley J, Lin GL, Galal U, Nair H, Aerssens J, Öner D, Langedijk A, Bont L, Wildenbeest JG, Martinon-Torres F, Rodríguez-Tenreiro Sánchez C, Nadel S, Openshaw P, Thwaites R, Widjojoatmodjo M, Zhang L, Nguyen TLA, Giaquinto C, Giordano G, Baraldi E, Pollard AJ. Presumed Risk Factors and Biomarkers for Severe Respiratory Syncytial Virus Disease and Related Sequelae: Protocol for an Observational Multicenter, Case-Control Study From the Respiratory Syncytial Virus Consortium in Europe (RESCEU). J Infect Dis 2021; 222:S658-S665. [PMID: 32794560 DOI: 10.1093/infdis/jiaa239] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Respiratory syncytial virus (RSV) is the leading viral pathogen associated with acute lower respiratory tract infection and hospitalization in children < 5 years of age worldwide. While there are known clinical risk factors for severe RSV infection, the majority of those hospitalized are previously healthy infants. There is consequently an unmet need to identify biomarkers that predict host response, disease severity, and sequelae. The primary objective is to identify biomarkers of severe RSV acute respiratory tract infection (ARTI) in infants. Secondary objectives include establishing biomarkers associated with respiratory sequelae following RSV infection and characterizing the viral load, RSV whole-genome sequencing, host immune response, and transcriptomic, proteomic, metabolomic and epigenetic signatures associated with RSV disease severity. Six hundred thirty infants will be recruited across 3 European countries: the Netherlands, Spain, and the United Kingdom. Participants will be recruited into 2 groups: (1) infants with confirmed RSV ARTI (includes upper and lower respiratory tract infections), 500 without and 50 with comorbidities; and (2) 80 healthy controls. At baseline, participants will have nasopharyngeal, blood, buccal, stool, and urine samples collected, plus complete a questionnaire and 14-day symptom diary. At convalescence (7 weeks ± 1 week post-ARTI), specimen collection will be repeated. Laboratory measures will be correlated with symptom severity scores to identify corresponding biomarkers of disease severity. CLINICAL TRIALS REGISTRATION NCT03756766.
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Affiliation(s)
| | - Simon B Drysdale
- Department of Paediatrics, Oxford Vaccine Group, Oxford, United Kingdom.,Department of Paediatrics, St George's University Hospital NHS Foundation Trust, London, United Kingdom
| | - Hannah Robinson
- Department of Paediatrics, Oxford Vaccine Group, Oxford, United Kingdom
| | | | - Luke Blackwell
- Department of Paediatrics, Oxford Vaccine Group, Oxford, United Kingdom
| | - Joseph McGinley
- Department of Paediatrics, Oxford Vaccine Group, Oxford, United Kingdom
| | - Gu-Lung Lin
- Department of Paediatrics, Oxford Vaccine Group, Oxford, United Kingdom
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Oxford, United Kingdom
| | - Harish Nair
- Usher Institute, University of Edinburgh, Old Medical School, Edinburgh, United Kingdom
| | - Jeroen Aerssens
- Infectious Diseases, Janssen Pharmaceutica NV, Beerse, Belgium
| | - Deniz Öner
- Infectious Diseases, Janssen Pharmaceutica NV, Beerse, Belgium
| | - Annefleur Langedijk
- Department of Paediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Louis Bont
- Department of Paediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Joanne G Wildenbeest
- Department of Paediatrics, Immunology and Infectious Disease, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Federico Martinon-Torres
- Translational Paediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain.,Genetics, Vaccines, Infections and Pediatrics Research Group, Instituto de Investigación Sanitaria de Santiago, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Carmen Rodríguez-Tenreiro Sánchez
- Translational Paediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain.,Genetics, Vaccines, Infections and Pediatrics Research Group, Instituto de Investigación Sanitaria de Santiago, University of Santiago de Compostela, Santiago de Compostela, Spain
| | - Simon Nadel
- Department of Paediatrics, Imperial College, London, United Kingdom
| | - Peter Openshaw
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ryan Thwaites
- Faculty of Medicine, National Heart and Lung Institute, Imperial College, London, United Kingdom
| | | | | | | | - Carlo Giaquinto
- Fondazione Penta Onlus, Torre di Ricerca Pediatrica, Padova, Italy
| | | | - Eugenio Baraldi
- Fondazione Penta Onlus, Torre di Ricerca Pediatrica, Padova, Italy
| | - Andrew J Pollard
- Department of Paediatrics, Oxford Vaccine Group, Oxford, United Kingdom
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15
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Mitting RB, Peshimam N, Lillie J, Donnelly P, Ghazaly M, Nadel S, Ray S, Tibby SM. Invasive Mechanical Ventilation for Acute Viral Bronchiolitis: Retrospective Multicenter Cohort Study. Pediatr Crit Care Med 2021; 22:231-240. [PMID: 33512983 DOI: 10.1097/pcc.0000000000002631] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Bronchiolitis is a leading cause of PICU admission and a major contributor to resource utilization during the winter season. Management in mechanically ventilated patients with bronchiolitis is not standardized. We aimed to assess whether variations exist in management between the centers and then to assess if differences in PICU outcomes are found. DESIGN Retrospective cohort study. SETTING Three tertiary PICUs (Centers A, B, and C) in London, United Kingdom. PATIENTS Patients under 1 year of age (n = 462) who received invasive mechanical ventilation for acute viral bronchiolitis from 2012-2016. INTERVENTIONS None. DESIGN Retrospective cohort study. MEASUREMENTS AND MAIN RESULTS Data collected include all sedative agents administered, 48 hour cumulative fluid balance and location of endotracheal tube (oral or nasal). Primary outcome was duration of invasive mechanical ventilation. A generalized linear model was used to test for differences in duration of invasive mechanical ventilation between centers after adjustment for confounders: corrected gestational age, oxygen saturation index, bacterial coinfection, prematurity, respiratory syncytial virus status, risk of mortality score and comorbidity. Baseline characteristics were similar, other than a higher risk of mortality score at center A and higher admission oxygen saturation index at center C. Center A was associated with utilization of the most benzodiazepine and opiate sedation, the fewest nasal endotracheal tubes, and the highest mean cumulative fluid balance at 48 hours.Center A had an adjusted mean duration of invasive mechanical ventilation that was 44% longer than center C (95% CI, 25-66%; p < 0.001).The majority of confounders had an association with the duration of invasive mechanical ventilation; all were biologically plausible. Corrected gestational age was negatively associated with the duration of invasive mechanical ventilation for preterm infants less than 32 weeks, but not for term or 32-37 week infants (interaction effect). This meant that at a corrected age of 0 months, a less than 32-week infant had a mean duration that was 55% greater than a term infant: this effect had disappeared by 8 months old. CONCLUSIONS Between-center variations exist in both practices and outcomes. The relationship between these two findings could be further tested through implementation science with "optimal care bundles."
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Affiliation(s)
- Rebecca B Mitting
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Niha Peshimam
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Jon Lillie
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, United Kingdom
| | - Peter Donnelly
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, United Kingdom
| | - Marwa Ghazaly
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Assiut University, Assiut, Egypt
| | - Simon Nadel
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Samiran Ray
- Pediatric Intensive Care Unit, Great Ormond Street Hospital for Children, London, United Kingdom
- Respiratory, Critical Care and Anaesthesia Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Shane M Tibby
- Pediatric Intensive Care Unit, Evelina London Children's Hospital, London, United Kingdom
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16
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Mashbat B, Bellos E, Hodeib S, Bidmos F, Thwaites RS, Lu Y, Wright VJ, Herberg JA, Klobassa DS, Zenz W, Hansel TT, Nadel S, Langford PR, Schlapbach LJ, Li MS, Redinbo MR, Di YP, Levin M, Sancho-Shimizu V. A Rare Mutation in SPLUNC1 Affects Bacterial Adherence and Invasion in Meningococcal Disease. Clin Infect Dis 2021; 70:2045-2053. [PMID: 31504285 PMCID: PMC7201419 DOI: 10.1093/cid/ciz600] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 06/28/2019] [Indexed: 01/06/2023] Open
Abstract
Background Neisseria meningitidis (Nm) is a nasopharyngeal commensal carried by healthy individuals. However, invasive infections occurs in a minority of individuals, with devastating consequences. There is evidence that common polymorphisms are associated with invasive meningococcal disease (IMD), but the contributions of rare variants other than those in the complement system have not been determined. Methods We identified familial cases of IMD in the UK meningococcal disease study and the European Union Life-Threatening Infectious Disease Study. Candidate genetic variants were identified by whole-exome sequencing of 2 patients with familial IMD. Candidate variants were further validated by in vitro assays. Results Exomes of 2 siblings with IMD identified a novel heterozygous missense mutation in BPIFA1/SPLUNC1. Sequencing of 186 other nonfamilial cases identified another unrelated IMD patient with the same mutation. SPLUNC1 is an innate immune defense protein expressed in the nasopharyngeal epithelia; however, its role in invasive infections is unknown. In vitro assays demonstrated that recombinant SPLUNC1 protein inhibits biofilm formation by Nm, and impedes Nm adhesion and invasion of human airway cells. The dominant negative mutant recombinant SPLUNC1 (p.G22E) showed reduced antibiofilm activity, increased meningococcal adhesion, and increased invasion of cells, compared with wild-type SPLUNC1. Conclusions A mutation in SPLUNC1 affecting mucosal attachment, biofilm formation, and invasion of mucosal epithelial cells is a new genetic cause of meningococcal disease.
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Affiliation(s)
- Bayarchimeg Mashbat
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Evangelos Bellos
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Stephanie Hodeib
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Fadil Bidmos
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Ryan S Thwaites
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Yaxuan Lu
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Victoria J Wright
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Jethro A Herberg
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Daniela S Klobassa
- Department of Pediatric and Adolescence Surgery, Division of General Pediatric Surgery, Medical University Graz, Austria
| | - Werner Zenz
- Department of Pediatric and Adolescence Surgery, Division of General Pediatric Surgery, Medical University Graz, Austria
| | - Trevor T Hansel
- National Heart and Lung Institute, Imperial College London, United Kingdom
| | - Simon Nadel
- Paediatric Intensive Care Unit, St. Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom
| | - Paul R Langford
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Luregn J Schlapbach
- Faculty of Medicine Brisbane, The University of Queensland Brisbane, Australia.,Paediatric Critical Care Research Group, The University of Queensland Brisbane, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.,Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Switzerland
| | - Ming-Shi Li
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Matthew R Redinbo
- Department of Chemistry, University of North Carolina, Chapel Hill.,Department of Biochemistry and Biophysics, University of North Carolina, Chapel Hill.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill
| | - Y Peter Di
- Department of Environmental and Occupational Health, University of Pittsburgh, Pennsylvania
| | - Michael Levin
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
| | - Vanessa Sancho-Shimizu
- Department of Paediatric Infectious Diseases, Division of Medicine, Imperial College London, Norfolk Place, United Kingdom
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17
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Ghazaly MMH, Abu Faddan NH, Raafat DM, Mohammed NA, Nadel S. Acute viral bronchiolitis as a cause of pediatric acute respiratory distress syndrome. Eur J Pediatr 2021; 180:1229-1234. [PMID: 33161501 PMCID: PMC7648537 DOI: 10.1007/s00431-020-03852-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 11/29/2022]
Abstract
The Pediatric Acute Lung Injury Consensus Conference (PALICC) published pediatric-specific guidelines for the definition, management, and research in pediatric acute respiratory distress syndrome (PARDS). Acute viral bronchiolitis (AVB) remains one of the leading causes of admission to PICU. Respiratory syncytial virus (RSV) is the most common cause of AVB. We aimed to evaluate the incidence of PARDS in AVB and identify the risk of RSV as a trigger pathogen for PARDS. This study is a retrospective single-center observational cohort study including children < 2 years of age admitted to the pediatric intensive care unit at St Mary's Hospital, London, and presented with AVB in 3 years (2016-2018). Clinical and demographic data was collected; PALICC criteria were applied to define PARDS. Data was expressed as median (IQR range); non-parametric tests were used. In this study, 144 infants with acute viral bronchiolitis were admitted to PICU in the study period. Thirty-nine infants fulfilled criteria of PARDS with RSV as the most common virus identified. Bacterial infection was identified as a risk factor for development of PARDS in infants with AVB.Conclusion: AVB is an important cause of PARDS in infants. RSV is associated with a higher risk of PARDS in AVB. Bacterial co-infection is a significant risk factor for development of PARDS in AVB. What is Known: • Bronchiolitis is a common cause of respiratory failure in children under 2 years. • ARDS is a common cause of PICU admission. What is New: • Evaluation of bronchiolitis as a cause of PARDS according to the PALLIC criteria. • Evaluation of different viruses' outcome in PARDS especially RSV as a commonest cause of AVB.
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Affiliation(s)
- Marwa M. H. Ghazaly
- Department of Pediatrics, Children University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College London Healthcare NHS Trust, London, UK
| | - Nagla H. Abu Faddan
- Department of Pediatrics, Children University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Duaa M. Raafat
- Department of Pediatrics, Children University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Nagwa A. Mohammed
- Department of Pediatrics, Children University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Simon Nadel
- Department of Pediatrics, Children University Hospital, Faculty of Medicine, Assiut University, Assiut, Egypt
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College London Healthcare NHS Trust, London, UK
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18
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Boutry O, Nadel S. Institutional Drivers of Environmental Innovation: Evidence from French Industrial Firms. Journal of Innovation Economics & Management 2020. [DOI: 10.3917/jie.034.0135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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19
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 2020; 46:10-67. [PMID: 32030529 PMCID: PMC7095013 DOI: 10.1007/s00134-019-05878-6] [Citation(s) in RCA: 266] [Impact Index Per Article: 66.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objectives To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. Design A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. Methods The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, “in our practice” statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. Results The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 49 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, “in our practice” statements were provided. In addition, 52 research priorities were identified. Conclusions A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, UK
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, UK
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.,Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA, USA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | | | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH, USA
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA, USA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, Singapore.,Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Mark E Nunnally
- New York University Langone Medical Center, New York, NY, USA
| | | | - Raina M Paul
- Advocate Children's Hospital, Park Ridge, IL, USA
| | - Adrienne G Randolph
- Department of Anesthesiology, Critical Care and Pain, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,College of Nursing, University of Iowa, Iowa City, IA, USA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN, USA
| | | | | | | | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-Sur-Yvette, France
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20
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Abu-Raya B, Migliori GB, O'Ryan M, Edwards K, Torres A, Alffenaar JW, Märtson AG, Centis R, D'Ambrosio L, Flanagan K, Hung I, Lauretani F, Leung CC, Leuridan E, Maertens K, Maggio MG, Nadel S, Hens N, Niesters H, Osterhaus A, Pontali E, Principi N, Rossato Silva D, Omer S, Spanevello A, Sverzellati N, Tan T, Torres-Torreti JP, Visca D, Esposito S. Coronavirus Disease-19: An Interim Evidence Synthesis of the World Association for Infectious Diseases and Immunological Disorders (Waidid). Front Med (Lausanne) 2020; 7:572485. [PMID: 33195319 PMCID: PMC7662576 DOI: 10.3389/fmed.2020.572485] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 10/12/2020] [Indexed: 12/19/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) is a rapidly evolving, highly transmissible, and potentially lethal pandemic caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of June 11 2020, more than 7,000,000 COVID-19 cases have been reported worldwide, and more than 400,000 patients have died, affecting at least 188 countries. While literature on the disease is rapidly accumulating, an integrated, multinational perspective on clinical manifestations, immunological effects, diagnosis, prevention, and treatment of COVID-19 can be of global benefit. We aimed to synthesize the most relevant literature and experiences in different parts of the world through our global consortium of experts to provide a consensus-based document at this early stage of the pandemic.
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Affiliation(s)
- Bahaa Abu-Raya
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Giovanni Battista Migliori
- Istituti Clinici Scientifici Maugeri, Istituto di Ricerca e Cura a Carattere Scientifico, Tradate, Italy
| | - Miguel O'Ryan
- Faculty of Medicine, Institute of Biomedical Sciences and Institute of Immunology and Immunotherapy, University of Chile, Santiago, Chile
| | - Kathryn Edwards
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Antoni Torres
- Respiratory and Intensive Care Unit, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain
| | - Jan-Willem Alffenaar
- Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Sydney, NSW, Australia
- Westmead Hospital, Sydney, NSW, Australia
- Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Anne-Grete Märtson
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Rosella Centis
- Istituti Clinici Scientifici Maugeri, Istituto di Ricerca e Cura a Carattere Scientifico, Tradate, Italy
| | | | - Katie Flanagan
- University of Tasmania, Monash University, RMIT University, Hobart, Australia
| | - Ivan Hung
- Queen Mary Hospital, Hong Kong, China
| | - Fulvio Lauretani
- Geriatric Clinic Unit, Department of Medicine and Surgery, University-Hospital of Parma, University of Parma, Parma, Italy
| | - Chi Chi Leung
- Hong Kong Tuberculosis, Chest and Heart Diseases Association, Hong Kong, China
| | - Elke Leuridan
- Faculty of Medicine and Health Sciences, Vaccine and Infectious Diseases Institute, University of Antwerp, Antwerp, Belgium
| | - Kirsten Maertens
- Faculty of Medicine and Health Sciences, Vaccine and Infectious Diseases Institute, University of Antwerp, Antwerp, Belgium
| | - Marcello Giuseppe Maggio
- Geriatric Clinic Unit, Department of Medicine and Surgery, University-Hospital of Parma, University of Parma, Parma, Italy
| | | | - Niel Hens
- Data Science Institute, Hasselt University, Hasselt, Belgium
- Centre for Health Economic Research and Modelling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
| | - Hubert Niesters
- Universitair Medisch Centrum Groningen, Groningen, Netherlands
| | | | - Emanuele Pontali
- Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
| | | | | | - Saad Omer
- Department of Internal Medicine (Infectious Diseases), Yale School of Medicine, New Haven, CT, United States
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
| | - Antonio Spanevello
- Istituti Clinici Scientifici Maugeri, Istituto di Ricerca e Cura a Carattere Scientifico, Tradate, Italy
| | - Nicola Sverzellati
- Radiology Unit, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Tina Tan
- Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Evanston, IL, United States
| | - Juan Pablo Torres-Torreti
- Department of Pediatrics and Pediatric Surgery, Faculty of Medicine, Dr. Luis Calvo Mackenna Hospital, University of Chile, Santiago, Chile
| | - Dina Visca
- Istituti Clinici Scientifici Maugeri, Istituto di Ricerca e Cura a Carattere Scientifico, Tradate, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, Pietro Barilla Children's Hospital, University of Parma, Parma, Italy
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21
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Weiss SL, Peters MJ, Alhazzani W, Agus MSD, Flori HR, Inwald DP, Nadel S, Schlapbach LJ, Tasker RC, Argent AC, Brierley J, Carcillo J, Carrol ED, Carroll CL, Cheifetz IM, Choong K, Cies JJ, Cruz AT, De Luca D, Deep A, Faust SN, De Oliveira CF, Hall MW, Ishimine P, Javouhey E, Joosten KFM, Joshi P, Karam O, Kneyber MCJ, Lemson J, MacLaren G, Mehta NM, Møller MH, Newth CJL, Nguyen TC, Nishisaki A, Nunnally ME, Parker MM, Paul RM, Randolph AG, Ranjit S, Romer LH, Scott HF, Tume LN, Verger JT, Williams EA, Wolf J, Wong HR, Zimmerman JJ, Kissoon N, Tissieres P. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med 2020; 21:e52-e106. [PMID: 32032273 DOI: 10.1097/pcc.0000000000002198] [Citation(s) in RCA: 458] [Impact Index Per Article: 114.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To develop evidence-based recommendations for clinicians caring for children (including infants, school-aged children, and adolescents) with septic shock and other sepsis-associated organ dysfunction. DESIGN A panel of 49 international experts, representing 12 international organizations, as well as three methodologists and three public members was convened. Panel members assembled at key international meetings (for those panel members attending the conference), and a stand-alone meeting was held for all panel members in November 2018. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. Teleconferences and electronic-based discussion among the chairs, co-chairs, methodologists, and group heads, as well as within subgroups, served as an integral part of the guideline development process. METHODS The panel consisted of six subgroups: recognition and management of infection, hemodynamics and resuscitation, ventilation, endocrine and metabolic therapies, adjunctive therapies, and research priorities. We conducted a systematic review for each Population, Intervention, Control, and Outcomes question to identify the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak, or as a best practice statement. In addition, "in our practice" statements were included when evidence was inconclusive to issue a recommendation, but the panel felt that some guidance based on practice patterns may be appropriate. RESULTS The panel provided 77 statements on the management and resuscitation of children with septic shock and other sepsis-associated organ dysfunction. Overall, six were strong recommendations, 52 were weak recommendations, and nine were best-practice statements. For 13 questions, no recommendations could be made; but, for 10 of these, "in our practice" statements were provided. In addition, 49 research priorities were identified. CONCLUSIONS A large cohort of international experts was able to achieve consensus regarding many recommendations for the best care of children with sepsis, acknowledging that most aspects of care had relatively low quality of evidence resulting in the frequent issuance of weak recommendations. Despite this challenge, these recommendations regarding the management of children with septic shock and other sepsis-associated organ dysfunction provide a foundation for consistent care to improve outcomes and inform future research.
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Affiliation(s)
- Scott L Weiss
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Mark J Peters
- Great Ormond Street Hospital for Children, London, United Kingdom
| | - Waleed Alhazzani
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael S D Agus
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Luregn J Schlapbach
- Paediatric Critical Care Research Group, The University of Queensland and Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Robert C Tasker
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Andrew C Argent
- Red Cross War Memorial Children's Hospital and University of Cape Town, Cape Town, South Africa
| | - Joe Brierley
- Great Ormond Street Hospital for Children, London, United Kingdom
| | | | | | | | | | - Karen Choong
- Department of Medicine, Division of Critical Care, and Department of Health Research Methods and Impact, McMaster University, Hamilton, ON, Canada
| | - Jeffry J Cies
- St. Christopher's Hospital for Children, Philadelphia, PA
| | | | - Daniele De Luca
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Physiopathology and Therapeutic Innovation Unit-INSERM U999, South Paris-Saclay University, Paris, France
| | - Akash Deep
- King's College Hospital, London, United Kingdom
| | - Saul N Faust
- University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | | | - Mark W Hall
- Nationwide Children's Hospital, Columbus, OH
| | | | | | | | - Poonam Joshi
- All India Institute of Medical Sciences, New Delhi, India
| | - Oliver Karam
- Children's Hospital of Richmond at VCU, Richmond, VA
| | | | - Joris Lemson
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Graeme MacLaren
- National University Health System, Singapore, and Royal Children's Hospital, Melbourne, VIC, Australia
| | - Nilesh M Mehta
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Akira Nishisaki
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | | | | | | | - Adrienne G Randolph
- Department of Pediatrics (to Dr. Agus), Department of Anesthesiology, Critical Care and Pain (to Drs. Mehta and Randolph), Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | | | - Lyvonne N Tume
- University of the West of England, Bristol, United Kingdom
| | - Judy T Verger
- Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA.,College of Nursing, University of Iowa, Iowa City, IA
| | | | - Joshua Wolf
- St. Jude Children's Research Hospital, Memphis, TN
| | | | | | - Niranjan Kissoon
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Pierre Tissieres
- Paris South University Hospitals-Assistance Publique Hopitaux de Paris, Paris, France.,Institute of Integrative Biology of the Cell-CNRS, CEA, Univ Paris Sud, Gif-sur-Yvette, France
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22
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Abstract
Meningococcemia is notorious for evasion of the host immune system and its rapid progression to fulminant disease, and serves as a unique model for pediatric sepsis. Illness severity is determined by complex interplays among host, pathogen, and environment. The inflammatory host response, including proinflammatory and anti-inflammatory responses in innate and adaptive immunity, skews toward a proinflammatory state. This leads to endothelial dysfunction and activation of the hemostatic response, which may lead to disseminated intravascular coagulation. This article reviews the pathogenesis of sepsis, in particular the inflammatory and hemostatic response in meningococcal sepsis.
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Affiliation(s)
- Navin P Boeddha
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Thomas Bycroft
- St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W21NY London, UK
| | - Simon Nadel
- St Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W21NY London, UK; Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - Jan A Hazelzet
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands.
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23
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Mitting RB, Ray S, Raffles M, Egan H, Goley P, Peters M, Nadel S. Improved oxygenation following methylprednisolone therapy and survival in paediatric acute respiratory distress syndrome. PLoS One 2019; 14:e0225737. [PMID: 31770398 PMCID: PMC6879165 DOI: 10.1371/journal.pone.0225737] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Accepted: 11/11/2019] [Indexed: 12/15/2022] Open
Abstract
Background Methylprednisolone remains a commonly used ancillary therapy for paediatric acute respiratory distress syndrome (PARDS), despite a lack of level 1 evidence to justify its use. When planning prospective trials it is useful to define response to therapy and to identify if there is differential response in certain patients, i.e. existence of ‘responders’ and ‘non responders’ to therapy. This retrospective, observational study carried out in 2 tertiary referral paediatric intensive care units aims to characterize the change in Oxygen Saturation Index, following the administration of low dose methylprednisolone in a cohort of patients with PARDS, to identify what proportion of children treated demonstrated response, whether any particular characteristics predict response to therapy, and to determine if a positive response to corticosteroids is associated with reduced Paediatric Intensive Care Unit mortality. Methods All patients who received prolonged, low dose, IV methylprednisolone for the specific indication of PARDS over a 5-year period (2011–2016) who met the PALICC criteria for PARDS at the time of commencement of steroid were included (n = 78).OSI was calculated four times per day from admission until discharge from PICU (or death). Patients with ≥20% improvement in their mean daily OSI within 72 hours of commencement of methylprednisolone were classified as ‘responders’. Primary outcome measure was survival to PICU discharge. Results Mean OSI of the cohort increased until the day of steroid commencement then improved thereafter. 59% of patients demonstrated a response to steroids. Baseline characteristics were similar between responders and non-responders. Survival to PICU discharge was significantly higher in ‘responders’ (74% vs 41% OR 4.14(1.57–10.87) p = 0.004). On multivariable analysis using likely confounders, response to steroid was an independent predictor of survival to PICU discharge (p = 0.002). Non-responders died earlier after steroid administration than responders (p = 0.003). Conclusions An improvement in OSI was observed in 60% of patients following initiation of low dose methylprednisolone therapy in this cohort of patients with PARDS. Baseline characteristics fail to demonstrate a difference between responders and non-responders. A 20% improvement in OSI after commencement of methylprednisolone was independently predictive of survival, Prospective trials are needed to establish if there is a benefit from this therapy.
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Affiliation(s)
- Rebecca B. Mitting
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
- * E-mail:
| | - Samiran Ray
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
- Respiratory, critical care and anaesthesia section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Michael Raffles
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Helen Egan
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Paul Goley
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Mark Peters
- Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, United Kingdom
- Respiratory, critical care and anaesthesia section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Simon Nadel
- Paediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, United Kingdom
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24
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Swieboda D, Guo Y, Sagawe S, Thwaites RS, Nadel S, Openshaw PJM, Culley FJ. OMIP-062: A 14-Color, 16-Antibody Panel for Immunophenotyping Human Innate Lymphoid, Myeloid and T Cells in Small Volumes of Whole Blood and Pediatric Airway Samples. Cytometry A 2019; 95:1231-1235. [PMID: 31633878 PMCID: PMC6972618 DOI: 10.1002/cyto.a.23907] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 01/22/2023]
Affiliation(s)
- Dawid Swieboda
- National Heart and Lung Institute, Imperial College London, London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Yanping Guo
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sophie Sagawe
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Ryan S Thwaites
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Peter J M Openshaw
- National Heart and Lung Institute, Imperial College London, London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
| | - Fiona J Culley
- National Heart and Lung Institute, Imperial College London, London, UK.,Asthma UK Centre in Allergic Mechanisms of Asthma, London, UK
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25
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Thwaites RS, Coates M, Ito K, Ghazaly M, Feather C, Abdulla F, Tunstall T, Jain P, Cass L, Rapeport G, Hansel TT, Nadel S, Openshaw P. Reduced Nasal Viral Load and IFN Responses in Infants with Respiratory Syncytial Virus Bronchiolitis and Respiratory Failure. Am J Respir Crit Care Med 2019; 198:1074-1084. [PMID: 29688024 DOI: 10.1164/rccm.201712-2567oc] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE Respiratory syncytial virus (RSV) bronchiolitis is a major cause of morbidity and mortality in infancy. Severe disease is believed to result from uncontrolled viral replication, an excessive immune response, or both. OBJECTIVES To determine RSV load and immune mediator levels in nasal mucosal lining fluid by serial sampling of nasal fluids from cases of moderate and severe bronchiolitis over the course of infection. METHODS Infants with viral bronchiolitis necessitating admission (n = 55) were recruited from a pediatric center during 2016 and 2017. Of these, 30 were RSV infected (18 "moderate" and 12 mechanically ventilated "severe"). Nasal fluids were sampled frequently over time using nasosorption devices and nasopharyngeal aspiration. Hierarchical clustering of time-weighted averages was performed to investigate cytokine and chemokine levels, and gene expression profiling was conducted. MEASUREMENTS AND MAIN RESULTS Unexpectedly, cases with severe RSV bronchiolitis had lower nasal viral loads and reduced IFN-γ and C-C chemokine ligand 5/RANTES (regulated upon activation, normal T cell expressed and secreted) levels than those with moderate disease, especially when allowance was made for disease duration (all P < 0.05). Reduced cytokine/chemokine levels in severe disease were also seen in children with other viral infections. Gene expression analysis of nasopharyngeal aspiration samples (n = 43) confirmed reduced type-I IFN gene expression in severe bronchiolitis accompanied by enhanced expression of MUC5AC and IL17A. CONCLUSIONS Infants with severe RSV bronchiolitis have lower nasal viral load, CXCL10 (C-X-C motif chemokine ligand 10)/IP-10, and type-I IFN levels than moderately ill children, but enhanced MUC5AC (mucin-5AC) and IL17A gene expression in nasal cells.
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Affiliation(s)
- Ryan S Thwaites
- 1 National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | | | - Marwa Ghazaly
- 3 Pediatric Intensive Care Unit, St. Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom; and.,4 Assiut University, Assiut, Egypt
| | - Calandra Feather
- 3 Pediatric Intensive Care Unit, St. Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom; and
| | - Farhana Abdulla
- 3 Pediatric Intensive Care Unit, St. Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom; and
| | - Tanushree Tunstall
- 1 National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Pooja Jain
- 1 National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | | | - Trevor T Hansel
- 1 National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Simon Nadel
- 3 Pediatric Intensive Care Unit, St. Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom; and
| | - Peter Openshaw
- 1 National Heart and Lung Institute, Imperial College London, London, United Kingdom
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26
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Levin M, Cunnington AJ, Wilson C, Nadel S, Lang HJ, Ninis N, McCulloch M, Argent A, Buys H, Moxon CA, Best A, Nijman RG, Hoggart CJ. Effects of saline or albumin fluid bolus in resuscitation: evidence from re-analysis of the FEAST trial. Lancet Respir Med 2019; 7:581-593. [PMID: 31196803 PMCID: PMC6593355 DOI: 10.1016/s2213-2600(19)30114-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/11/2019] [Accepted: 03/21/2019] [Indexed: 12/23/2022]
Abstract
BACKGROUND Fluid resuscitation is the recommended management of shock, but increased mortality in febrile African children in the FEAST trial. We hypothesised that fluid bolus-induced deaths in FEAST would be associated with detectable changes in cardiovascular, neurological, or respiratory function, oxygen carrying capacity, and blood biochemistry. METHODS We developed composite scores for respiratory, cardiovascular, and neurological function using vital sign data from the FEAST trial, and used them to compare participants from FEAST with those from four other cohorts and to identify differences between the bolus (n=2097) and no bolus (n=1044) groups of FEAST. We calculated the odds of adverse outcome for each ten-unit increase in baseline score using logistic regression for each cohort. Within FEAST participants, we also compared haemoglobin and plasma biochemistry between bolus and non-bolus patients, assessed the effects of these factors along with the vital sign scores on the contribution of bolus to mortality using Cox proportional hazard models, and used Bayesian clustering to identify subgroups that differed in response to bolus. The FEAST trial is registered with ISRCTN, number ISRCTN69856593. FINDINGS Increasing respiratory (odds ratio 1·09, 95% CI 1·07-1·11), neurological (1·26, 1·21-1·31), and cardiovascular scores (1·09, 1·05-1·14) were associated with death in FEAST (all p<0·0001), and with adverse outcomes for specific scores in the four other cohorts. In FEAST, fluid bolus increased respiratory and neurological scores and decreased cardiovascular score at 1 h after commencement of the infusion. Fluid bolus recipients had mean 0·33 g/dL (95% CI 0·20-0·46) reduction in haemoglobin concentration after 8 h (p<0·0001), and at 24 h had a decrease of 1·41 mEq/L (95% CI 0·76-2·06; p=0·0002) in mean base excess and increase of 1·65 mmol/L (0·47-2·8; p=0·0070) in mean chloride, and a decrease of 0·96 mmol/L (0·45 to 1·47; p=0·0003) in bicarbonate. There were similar effects of fluid bolus in three patient subgroups, identified on the basis of their baseline characteristics. Hyperchloraemic acidosis and respiratory and neurological dysfunction induced by saline or albumin bolus explained the excess mortality due to bolus in Cox survival models. INTERPRETATION In the resuscitation of febrile children, albumin and saline boluses can cause respiratory and neurological dysfunction, hyperchloraemic acidosis, and reduction in haemoglobin concentration. The findings support the notion that fluid resuscitation with unbuffered electrolyte solutions may cause harm and their use should be cautioned. The effects of lower volumes of buffered solutions should be evaluated further. FUNDING Medical Research Council, Department for International Development, National Institute for Health Research, Imperial College Biomedical Research Centre.
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Affiliation(s)
- Michael Levin
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK.
| | - Aubrey J Cunnington
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Clare Wilson
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
| | - Simon Nadel
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK; Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Hans Joerg Lang
- Paediatric Referent, Médecins sans Frontières, Brussels, Belgium
| | - Nelly Ninis
- Department of Paediatrics, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | | | - Andrew Argent
- Red Cross Children's Hospital, Cape Town, South Africa
| | - Heloise Buys
- Red Cross Children's Hospital, Cape Town, South Africa
| | - Christopher A Moxon
- Wellcome Centre for Integrative Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, UK; Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Abigail Best
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Ruud G Nijman
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK; Department of Paediatric Emergency Medicine, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Clive J Hoggart
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, London, UK
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27
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Morin L, Kneyber M, Jansen NJG, Peters MJ, Javouhey E, Nadel S, Maclaren G, Schlapbach LJ, Tissieres P. Translational gap in pediatric septic shock management: an ESPNIC perspective. Ann Intensive Care 2019; 9:73. [PMID: 31254125 PMCID: PMC6598895 DOI: 10.1186/s13613-019-0545-4] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 06/13/2019] [Indexed: 02/06/2023] Open
Abstract
Background The Surviving Sepsis Campaign and the American College of Critical Care Medicine guidelines have provided recommendations for the management of pediatric septic shock patients. We conducted a survey among the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) members to assess variations to these recommendations. Methods A total of 114 pediatric intensive care physicians completed an electronic survey. The survey consisted of four standardized clinical cases exploring seven clinical scenarios. Results Among the seven different clinical scenarios, the types of fluids were preferentially non-synthetic colloids (albumin) and crystalloids (isotonic saline) and volume expansion was not limited to 60 ml/kg. Early intubation for mechanical ventilation was used by 70% of the participants. Norepinephrine was stated to be used in 94% of the PICU physicians surveyed, although dopamine or epinephrine is recommended as first-line vasopressors in pediatric septic shock. When norepinephrine was used, the addition of another inotrope was frequent. Specific drugs such as vasopressin or enoximone were used in < 20%. Extracorporeal life support was used or considered by 91% of the physicians audited in certain specific situations, whereas the use of high-flow hemofiltration was considered for 44%. Conclusions This pediatric septic shock management survey outlined variability in the current clinician-reported practice of pediatric septic shock management. As most recommendations are not supported by evidence, these findings outline some limitation of existing pediatric guidelines in regard to context and patient’s specificity. Electronic supplementary material The online version of this article (10.1186/s13613-019-0545-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luc Morin
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, South Paris University, Le Kremlin-Bicêtre, France
| | - Martin Kneyber
- Pediatric Intensive Care Unit, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands.,Critical Care, Anesthesiology, Peri-operative and Emergency Medicine (CAPE), University of Groningen, Groningen, The Netherlands
| | - Nicolaas J G Jansen
- Paediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mark J Peters
- Pediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Lyon University Hospitals, Hospices Civils de Lyon, Bron, France
| | - Simon Nadel
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Graeme Maclaren
- Department of Pediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Luregn Jan Schlapbach
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Brisbane, Australia.,Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.,Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Pierre Tissieres
- Pediatric Intensive Care Unit, Bicêtre University Hospital, AP-HP, South Paris University, Le Kremlin-Bicêtre, France. .,Integrative Biology of the Cell, CNRS, CEA, Paris South University, Paris Saclay University, Gif-sur-Yvette, France.
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28
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Inwald DP, Canter R, Woolfall K, Mouncey P, Zenasni Z, O’Hara C, Carter A, Jones N, Lyttle MD, Nadel S, Peters MJ, Harrison DA, Rowan KM. Restricted fluid bolus volume in early septic shock: results of the Fluids in Shock pilot trial. Arch Dis Child 2019; 104:426-431. [PMID: 30087153 PMCID: PMC6557227 DOI: 10.1136/archdischild-2018-314924] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 07/10/2018] [Accepted: 07/15/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the feasibility of Fluids in Shock, a randomised controlled trial (RCT) of restricted fluid bolus volume (10 mL/kg) versus recommended practice (20 mL/kg). DESIGN Nine-month pilot RCT with embedded mixed-method perspectives study. SETTING 13 hospitals in England. PATIENTS Children presenting to emergency departments with suspected infection and shock after 20 mL/kg fluid. INTERVENTIONS Patients were randomly allocated (1:1) to further 10 or 20 mL/kg fluid boluses every 15 min for up to 4 hours if still in shock. MAIN OUTCOME MEASURES These were based on progression criteria, including recruitment and retention, protocol adherence, separation, potential trial outcome measures, and parent and staff perspectives. RESULTS Seventy-five participants were randomised; two were withdrawn. 23 (59%) of 39 in the 10 mL/kg arm and 25 (74%) of 34 in the 20 mL/kg arm required a single trial bolus before the shock resolved. 79% of boluses were delivered per protocol in the 10 mL/kg arm and 55% in the 20 mL/kg arm. The volume of study bolus fluid after 4 hours was 44% lower in the 10 mL/kg group (mean 14.5 vs 27.5 mL/kg). The Paediatric Index of Mortality-2 score was 2.1 (IQR 1.6-2.7) in the 10 mL/kg group and 2.0 (IQR 1.6-2.5) in the 20 mL/kg group. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) admissions and PICU-free days at 30 days did not differ significantly between the groups. In the perspectives study, the trial was generally supported, although some problems with protocol adherence were described. CONCLUSIONS Participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. TRIAL REGISTRATION NUMBER ISRCTN15244462.
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Affiliation(s)
- David Philip Inwald
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK
| | - Ruth Canter
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Zohra Zenasni
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Caitlin O’Hara
- Department of Psychological Sciences, North West Hub for Trials Methodology, University of Liverpool, Liverpool, UK
| | | | | | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK,Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare London NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, Institute of Child Health, University College London Great Ormond Street, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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29
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Inwald D, Canter RR, Woolfall K, O'Hara CB, Mouncey PR, Zenasni Z, Hudson N, Saunders S, Carter A, Jones N, Lyttle MD, Nadel S, Peters MJ, Harrison DA, Rowan KM. Restricted fluid bolus versus current practice in children with septic shock: the FiSh feasibility study and pilot RCT. Health Technol Assess 2019; 22:1-106. [PMID: 30238870 DOI: 10.3310/hta22510] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There has been no randomised controlled trial (RCT) of fluid bolus therapy in paediatric sepsis in the developed world despite evidence that excess fluid may be associated with harm. OBJECTIVES To determine the feasibility of the Fluids in Shock (FiSh) trial - a RCT comparing restricted fluid bolus (10 ml/kg) with current practice (20 ml/kg) in children with septic shock in the UK. DESIGN (1) Qualitative feasibility study exploring parents' views about the pilot RCT. (2) Pilot RCT over a 9-month period, including integrated parental and staff perspectives study. SETTING (1) Recruitment took place across four NHS hospitals in England and on social media. (2) Recruitment took place across 13 NHS hospitals in England. PARTICIPANTS (1) Parents of children admitted to a UK hospital with presumed septic shock in the previous 3 years. (2) Children presenting to an emergency department with clinical suspicion of infection and shock after 20 ml/kg of fluid. Exclusion criteria were receipt of > 20 ml/kg of fluid, conditions requiring fluid restriction and the patient not for full active treatment (i.e. palliative care plan in place). Site staff and parents of children in the pilot were recruited to the perspectives study. INTERVENTIONS (1) None. (2) Children were randomly allocated (1 : 1) to 10- or 20-ml/kg fluid boluses every 15 minutes for 4 hours if in shock. MAIN OUTCOME MEASURES (1) Acceptability of FiSh trial, proposed consent model and potential outcome measures. (2) Outcomes were based on progression criteria, including recruitment and retention rates, protocol adherence and separation between the groups, and collection and distribution of potential outcome measures. RESULTS (1) Twenty-one parents were interviewed. All would have consented for the pilot study. (2) Seventy-five children were randomised, 40 to the 10-ml/kg fluid bolus group and 35 to the 20-ml/kg fluid bolus group. Two children were withdrawn. Although the anticipated recruitment rate was achieved, there was variability across the sites. Fifty-nine per cent of children in the 10-ml/kg fluid bolus group and 74% in the 20-ml/kg fluid bolus group required only a single trial bolus before shock resolved. The volume of fluid (in ml/kg) was 35% lower in the first hour and 44% lower over the 4-hour period in the 10-ml/kg fluid bolus group. Fluid boluses were delivered per protocol (volume and timing) for 79% of participants in the 10-ml/kg fluid bolus group and for 55% in the 20-ml/kg fluid bolus group, mainly as a result of delivery not being completed within 15 minutes. There were no deaths. Length of hospital stay, paediatric intensive care unit (PICU) transfers, and days alive and PICU free did not differ significantly between the groups. Two adverse events were reported in each group. A questionnaire was completed by 45 parents, 20 families and seven staff were interviewed and 20 staff participated in focus groups. Although a minority of site staff lacked equipoise in favour of more restricted boluses, all supported the trial. CONCLUSIONS Even though a successful feasibility and pilot RCT were conducted, participants were not as unwell as expected. A larger trial is not feasible in its current design in the UK. FUTURE WORK Further observational work is required to determine the epidemiology of severe childhood infection in the UK in the postvaccine era. TRIAL REGISTRATION Current Controlled Trials ISRCTN15244462. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 51. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kerry Woolfall
- Department of Psychological Sciences, North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Caitlin B O'Hara
- Department of Psychological Sciences, North West Hub for Trials Methodology Research, University of Liverpool, Liverpool, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Zohra Zenasni
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nicholas Hudson
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Steven Saunders
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | | | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, University College London Great Ormond Street Institute of Child Health, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
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Ramasamy R, Willis L, Kadambari S, Kelly DF, Heath PT, Nadel S, Pollard AJ, Sadarangani M. Management of suspected paediatric meningitis: a multicentre prospective cohort study. Arch Dis Child 2018; 103:1114-1118. [PMID: 29436406 DOI: 10.1136/archdischild-2017-313913] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Revised: 01/12/2018] [Accepted: 01/20/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To quantify delays during management of children with suspected meningitis. DESIGN Multicentre prospective cohort study. SETTING Three UK tertiary paediatric centres; June 2011-June 2012 PATIENTS: 388 children aged <16 years hospitalised with suspected meningitis or undergoing lumbar puncture (LP) during sepsis evaluation. MAIN OUTCOME MEASURES Time of prehospital and in-hospital assessments, LP, antibiotic treatment and discharge; types of prehospital medical assessment and microbiological results. Data collected from hospital records and parental interview. RESULTS 220/388 (57%) children were seen by a medical professional prehospitalisation (143 by a general practitioner). Median times from initial hospital assessment to LP and antibiotic administration were 4.8 hours and 3.1 hours, respectively; 62% of children had their LP after antibiotic treatment. Median time to LP was shorter for children aged <3 months (3.0 hours) than those aged 3-23 months (6.2 hours, P<0.001) or age ≥2 years (20.3 hours, P<0.001). In meningitis of unknown cause, cerebrospinal fluid (CSF) PCR was performed for meningococcus in 7%, pneumococcus in 10% and enterovirus in 76%. When no pathogen was identified, hospital stay was longer if LP was performed after antibiotics (median 12.5 days vs 5.0 days, P=0.037). CONCLUSIONS Most children had LP after antibiotics were administered, reducing yield from CSF culture, and PCRs were underused despite national recommendations. These deficiencies reduce the ability to exclude bacterial meningitis, increasing unnecessary hospital stay and antibiotic treatment.
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Affiliation(s)
- Roshan Ramasamy
- Department of Emergency Medicine, Northwick Park Hospital, London, UK
| | - Louise Willis
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Seilesh Kadambari
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Dominic F Kelly
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Paul T Heath
- Paediatric Infectious Diseases Research Group, Institute for Infection and Immunity, St George's, University of London, London, UK
| | - Simon Nadel
- Department of Paediatrics, St Mary's Hospital, London, UK
| | - Andrew J Pollard
- Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
INTRODUCTION Respiratory Syncytial Virus (RSV) is the most common cause of Acute Bronchiolitis (AVB) in infants. AVB causes significant morbidity and mortality worldwide, most deaths occurring in the developing world. AVB causes respiratory distress in infants, leading to respiratory failure in some cases. Disease is more severe in infants with risk factors, such as prematurity, chronic cardiac and lung disease and immunodeficiency. Areas covered: Despite major advances in supportive care in the developed world, which has led to a significant reduction in mortality, treatment remains symptomatic and supportive. No specific antiviral treatment has yet proven to be effective. Prevention of disease with monoclonal antibodies has proven to reduce illness severity in those with risk factors, however, this is prohibitively expensive, particularly for the developing world. Prospects for vaccine development are improving. However, because most disease is in young infants, maternal immunization is necessary. However, due to the transient nature of RSV immunity and the circulation of multiple subtypes, vaccines proven to be effective in adult challenge models have yet to be translated to protection in infants. Expert commentary: Despite advances in preventative treatments, adherence to evidence-based guidelines provides the best prospect for successful reduction in morbidity and mortality.
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Affiliation(s)
- Marwa Ghazaly
- a Paediatric Intensive Care, Paediatric Intensive Care Unit , St. Mary's Hospital , London , UK.,b Department of Paediatrics , Assuit University , Assiut , Egypt
| | - Simon Nadel
- a Paediatric Intensive Care, Paediatric Intensive Care Unit , St. Mary's Hospital , London , UK
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32
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Feinstein Y, Walker JC, Peters MJ, Nadel S, Pathan N, Edmonds N, Herberg J, Kaforou M, Wright V, Levin M, Ramnarayan P. Cohort profile of the Biomarkers of Acute Serious Illness in Children (BASIC) study: a prospective multicentre cohort study in critically ill children. BMJ Open 2018; 8:e024729. [PMID: 30413517 PMCID: PMC6231583 DOI: 10.1136/bmjopen-2018-024729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/03/2018] [Accepted: 09/26/2018] [Indexed: 12/16/2022] Open
Abstract
PURPOSE Despite significant progress, challenges remain in the management of critically ill children, including early identification of infection and organ failure and robust early risk stratification to predict poor outcome. The Biomarkers of Acute Serious Illness in Children study aims to identify genetic and biological pathways underlying the development of critical illness in infections and organ failure and those leading to poor outcome (death or severe disability) in children requiring emergency intensive care. PARTICIPANTS We recruited a prospective cohort of critically ill children undergoing emergency transport to four paediatric intensive care units (PICUs) in Southeast England between April 2014 and December 2016. FINDINGS TO DATE During the study period, 1017 patients were recruited by the regional PICU transport team, and blood and urine samples were obtained at/around first contact with the patient by the transport team. Consent for participation in the study was deferred until after PICU admission and 674 parents/carers were consented. Further samples (blood, urine, stool and throat swabs) were collected after consent. Samples were processed and stored for genomic, transcriptomic, proteomic and metabolomic analyses. Demographic, clinical and laboratory data at first contact, during PICU stay and at discharge, were collected, as were detailed data regarding infectious or non-infectious aetiology. In addition, 115 families have completed 12-month validated follow-up questionnaires to assess quality of life and child behaviour.The first phase of sample analyses (transcriptomic profiling) is currently in progress. FUTURE PLANS Stored samples will be analysed using genomic, proteomic and metabolic profiling. Advanced bioinformatics techniques will be used to identify biomarkers for early diagnosis of infection, identification of organ failure and risk stratification to predict poor outcome (death/severe disability). TRIAL REGISTRATION NUMBER NCT03238040.
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Affiliation(s)
- Yael Feinstein
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- Department of Paediatrics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Jennifer Claire Walker
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Simon Nadel
- Paediatric Intensive Care, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Nazima Pathan
- Paediatrics Intensive Care, Addenbrookes’ Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Naomi Edmonds
- Paediatric Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Jethro Herberg
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Myrsini Kaforou
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Victoria Wright
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Michael Levin
- Department of Medicine, Section for Paediatrics, Imperial College London, London, UK
| | - Padmanabhan Ramnarayan
- Paediatric Intensive Care, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
- Children’s Acute Transport Service, Great Ormond Street Hospital for Children NHS Trust, London, UK
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Caspani G, Corbet Burcher G, Garralda ME, Cooper M, Pierce CM, Als LC, Nadel S. Inflammation and psychopathology in children following PICU admission: an exploratory study. Evid Based Ment Health 2018; 21:139-144. [PMID: 30301824 PMCID: PMC6241628 DOI: 10.1136/ebmental-2018-300027] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 07/21/2018] [Accepted: 08/13/2018] [Indexed: 12/27/2022]
Abstract
Background Survivors of critical illness in childhood commonly display subsequent psychiatric symptoms including emotional and behavioural difficulties, and manifestations of post-traumatic stress disorder (PTSD). Anomalies in inflammatory profiles are an established finding in these childhood psychiatric conditions. Objective This exploratory study aimed to investigate whether abnormal peripheral blood inflammatory markers measured during paediatric intensive care unit (PICU) admission were associated with psychiatric symptoms after discharge. Methods We performed a prospective observational cohort study on 71 children with septic illness, meningoencephalitis and other critical disorders admitted to two PICUs between 2007 and 2010. 3–6 months following discharge, subjects were assessed for global psychiatric risk (ie, presence of emotional and behavioural difficulties on the parental Strengths and Difficulties Questionnaire (SDQ)), and for PTSD risk using the child-rated Impact of Events Scale (IES-8). Inflammatory and related biological markers were transcribed from PICU admission notes (white cell count, lymphocytes, neutrophils, C reactive protein (CRP), platelets, fibrinogen and lactate). Findings Global psychiatric risk at follow-up was associated with abnormal lymphocyte count during admission (χ2=6.757, p=0.014, n=48). In children with sepsis, partial correlation analyses controlling for age and gender highlighted associations between (i) SDQ scores and low lymphocyte count (r=−0.712; p=0.009, n=14), and (ii) IES-8 score and high CRP levels (r=0.823; p=0.006, n=11). These associations remained after correction for multiple comparisons. Conclusion These results support the hypothesis that acute inflammation may play a role in determining the development of psychopathology following PICU admission. Clinical implications If the findings are replicated, they may help to better highlight which children are at risk of post-PICU psychopathology and appropriately target follow-up.
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Affiliation(s)
- Giorgia Caspani
- Department of Surgery and Cancer, Imperial College London, London, UK
| | | | | | - Mehrengise Cooper
- Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Christine M Pierce
- Department of Paediatric Intensive Care, Great Ormond Street Hospital, London, UK
| | - Lorraine C Als
- Centre for Psychiatry, Imperial College London, London, UK
| | - Simon Nadel
- Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
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Corbet Burcher G, Picouto MD, Als LC, Cooper M, Pierce CM, Nadel S, Garralda ME. Post-traumatic stress after PICU and corticosteroid use. Arch Dis Child 2018; 103:887-889. [PMID: 29175821 DOI: 10.1136/archdischild-2017-314157] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Revised: 11/08/2017] [Accepted: 11/09/2017] [Indexed: 11/04/2022]
Abstract
AIM To examine the association between corticosteroid use in paediatric intensive care units (PICU) and subsequent symptoms of post-traumatic stress disorder (PTSD). METHODS The subjects were children aged 8-16 years admitted to PICU with sepsis, meningoencephalitis (ME) and other disorders. Illness information was extracted from case notes; 3-6 months post discharge children completed a PTSD symptom questionnaire (eight-item Impact of Events Scale (IES-8)) assessing intrusion and avoidance symptoms. Saliva samples were also collected for cortisol profile analysis. RESULTS 53 children completed the IES-8 questionnaires. 33 provided saliva samples. 19 (36%) received corticosteroids. In children with sepsis (n=15), corticosteroid use was associated with significantly lower PTSD intrusion symptom scores. There was a trend towards an association between corticosteroid use and lower evening cortisol levels. There was a comparable but weaker trend in children with ME. DISCUSSION Corticosteroid use may be associated with fewer PTSD symptoms and lower evening cortisol levels following PICU admission in children with sepsis.
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Affiliation(s)
| | - Maria D Picouto
- Coslada Mental Health Service, Department of Child and Adolescent Psychiatry and Psychology, Hospital Infantil Universitario del Niño Jesús, Madrid, Spain
| | - Lorraine C Als
- Centre for Psychiatry, Department of Medicine, Imperial College London, London, UK
| | - Mehrengise Cooper
- Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Christine M Pierce
- Department of Paediatric Intensive Care, Great Ormond Street Hospital For Children NHS Trust, London, UK
| | - Simon Nadel
- Department of Paediatric Intensive Care, St Mary's Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - M Elena Garralda
- Centre for Psychiatry, Department of Medicine, Imperial College London, London, UK
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35
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Bidmos FA, Nadel S, Screaton GR, Kroll JS, Langford PR. Cross-Reactive Bactericidal Antimeningococcal Antibodies Can Be Isolated From Convalescing Invasive Meningococcal Disease Patients Using Reverse Vaccinology 2.0. Front Immunol 2018; 9:1621. [PMID: 30061891 PMCID: PMC6055031 DOI: 10.3389/fimmu.2018.01621] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 06/29/2018] [Indexed: 11/17/2022] Open
Abstract
The threat from invasive meningococcal disease (IMD) remains a serious source of concern despite the licensure and availability of vaccines. A limitation of current serogroup B vaccines is the breadth of coverage afforded, resulting from the capacity for extensive variation of the meningococcus and its huge potential for the generation of further diversity. Thus, the continuous search for candidate antigens that will compose supplementary or replacement vaccines is mandated. Here, we describe successful efforts to utilize the reverse vaccinology 2.0 approach to identify novel functional meningococcal antigens. In this study, eight broadly cross-reactive sequence-specific antimeningococcal human monoclonal antibodies (hmAbs) were cloned from 4 ml of blood taken from a 7-month-old sufferer of IMD. Three of these hmAbs possessed human complement-dependent bactericidal activity against meningococcal serogroup B strains of disparate PorA and 4CMenB antigen sequence types, strongly suggesting that the target(s) of these bactericidal hmAbs are not PorA (the immunodominant meningococcal antigen), factor-H binding protein, or other components of current meningococcal vaccines. Reactivity of the bactericidal hmAbs was confirmed to a single ca. 35 kDa protein in western blots. Unequivocal identification of this antigen is currently ongoing. Collectively, our results provide proof-of-principle for the use of reverse vaccinology 2.0 as a powerful tool in the search for alternative meningococcal vaccine candidate antigens.
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Affiliation(s)
- Fadil A Bidmos
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Simon Nadel
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom.,St. Mary's Hospital, Paddington, London, United Kingdom
| | - Gavin R Screaton
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - J Simon Kroll
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
| | - Paul R Langford
- Section of Paediatrics, Department of Medicine, Imperial College London, London, United Kingdom
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36
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Boeddha NP, Schlapbach LJ, Driessen GJ, Herberg JA, Rivero-Calle I, Cebey-López M, Klobassa DS, Philipsen R, de Groot R, Inwald DP, Nadel S, Paulus S, Pinnock E, Secka F, Anderson ST, Agbeko RS, Berger C, Fink CG, Carrol ED, Zenz W, Levin M, van der Flier M, Martinón-Torres F, Hazelzet JA, Emonts M. Mortality and morbidity in community-acquired sepsis in European pediatric intensive care units: a prospective cohort study from the European Childhood Life-threatening Infectious Disease Study (EUCLIDS). Crit Care 2018; 22:143. [PMID: 29855385 PMCID: PMC5984383 DOI: 10.1186/s13054-018-2052-7] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 04/29/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sepsis is one of the main reasons for non-elective admission to pediatric intensive care units (PICUs), but little is known about determinants influencing outcome. We characterized children admitted with community-acquired sepsis to European PICUs and studied risk factors for mortality and disability. METHODS Data were collected within the collaborative Seventh Framework Programme (FP7)-funded EUCLIDS study, which is a prospective multicenter cohort study aiming to evaluate genetic determinants of susceptibility and/or severity in sepsis. This report includes 795 children admitted with community-acquired sepsis to 52 PICUs from seven European countries between July 2012 and January 2016. The primary outcome measure was in-hospital death. Secondary outcome measures were PICU-free days censured at day 28, hospital length of stay, and disability. Independent predictors were identified by multivariate regression analysis. RESULTS Patients most commonly presented clinically with sepsis without a source (n = 278, 35%), meningitis/encephalitis (n = 182, 23%), or pneumonia (n = 149, 19%). Of 428 (54%) patients with confirmed bacterial infection, Neisseria meningitidis (n = 131, 31%) and Streptococcus pneumoniae (n = 78, 18%) were the main pathogens. Mortality was 6% (51/795), increasing to 10% in the presence of septic shock (45/466). Of the survivors, 31% were discharged with disability, including 24% of previously healthy children who survived with disability. Mortality and disability were independently associated with S. pneumoniae infections (mortality OR 4.1, 95% CI 1.1-16.0, P = 0.04; disability OR 5.4, 95% CI 1.8-15.8, P < 0.01) and illness severity as measured by Pediatric Index of Mortality (PIM2) score (mortality OR 2.8, 95% CI 1.3-6.1, P < 0.01; disability OR 3.4, 95% CI 1.8-6.4, P < 0.001). CONCLUSIONS Despite widespread immunization campaigns, invasive bacterial disease remains responsible for substantial morbidity and mortality in critically ill children in high-income countries. Almost one third of sepsis survivors admitted to the PICU were discharged with some disability. More research is required to delineate the long-term outcome of pediatric sepsis and to identify interventional targets. Our findings emphasize the importance of improved early sepsis-recognition programs to address the high burden of disease.
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Affiliation(s)
- Navin P. Boeddha
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Luregn J. Schlapbach
- Faculty of Medicine, The University of Queensland, St Lucia Queensland, Brisbane, 4072 Australia
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Aubigny Place, Raymond Terrace, Brisbane, Australia
- Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital, Children’s Health Queensland, 501 Stanley St, Brisbane, Australia
- Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 8, 3010 Bern, Switzerland
| | - Gertjan J. Driessen
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Paediatrics, Juliana Children’s Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
| | - Jethro A. Herberg
- Section of Pediatrics, Imperial College London, Level 2, Faculty Building South Kensington Campus, London, SW7 2AZ UK
| | - Irene Rivero-Calle
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
| | - Miriam Cebey-López
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
| | - Daniela S. Klobassa
- Department of General Paediatrics, Medical University of Graz, Auenbruggerplatz 34/2, A-8036 Graz, Austria
| | - Ria Philipsen
- Radboudumc Technology Center Clinical Studies, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Ronald de Groot
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - David P. Inwald
- Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ UK
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
| | - Simon Nadel
- Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ UK
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
| | - Stéphane Paulus
- Division of Paediatric Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Eaton Rd, Liverpool, L12 2AP UK
- Institute of Infection & Global Health, University of Liverpool, 8 West Derby St, Liverpool, L7 3EA UK
| | - Eleanor Pinnock
- Micropathology Ltd, University of Warwick Science Park, Venture Centre, Sir William Lyons Road, Coventry, CV4 7EZ UK
| | - Fatou Secka
- Medical research Council Unit, Atlantic Boulevard, Fajara, P. O. Box 273, Banjul, The Gambia
| | - Suzanne T. Anderson
- Medical research Council Unit, Atlantic Boulevard, Fajara, P. O. Box 273, Banjul, The Gambia
| | - Rachel S. Agbeko
- Department of Paediatric Intensive Care, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- Institute of Cellular Medicine, Newcastle University, 4th Floor, William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
| | - Christoph Berger
- Division of Infectious Diseases and Hospital Epidemiology, and Children’s Research Center, University Children’s Hospital Zurich, Steinwiesenstrasse 75, 8032 Zurich, Switzerland
| | - Colin G. Fink
- Micropathology Ltd, University of Warwick Science Park, Venture Centre, Sir William Lyons Road, Coventry, CV4 7EZ UK
| | - Enitan D. Carrol
- Institute of Infection & Global Health, University of Liverpool, 8 West Derby St, Liverpool, L7 3EA UK
| | - Werner Zenz
- Department of General Paediatrics, Medical University of Graz, Auenbruggerplatz 34/2, A-8036 Graz, Austria
| | - Michael Levin
- Section of Pediatrics, Imperial College London, Level 2, Faculty Building South Kensington Campus, London, SW7 2AZ UK
| | - Michiel van der Flier
- Radboudumc Technology Center Clinical Studies, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Pediatric Infectious Diseases and Immunology Amalia Children’s Hospital, and Radboudumc Expertise Center for Immunodeficiency and Autoinflammation (REIA), Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
| | - Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
| | - Jan A. Hazelzet
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
| | - Marieke Emonts
- Institute of Cellular Medicine, Newcastle University, 4th Floor, William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Paediatric Infectious Diseases and Immunology Department, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Westgate Rd, Newcastle upon Tyne, NE4 5PL UK
| | - on behalf of the EUCLIDS consortium
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Department of Pediatrics, Division of Pediatric Infectious Diseases & Immunology, Erasmus MC-Sophia Children’s Hospital, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Faculty of Medicine, The University of Queensland, St Lucia Queensland, Brisbane, 4072 Australia
- Paediatric Critical Care Research Group, Mater Research Institute, The University of Queensland, Aubigny Place, Raymond Terrace, Brisbane, Australia
- Paediatric Intensive Care Unit, Lady Cilento Children’s Hospital, Children’s Health Queensland, 501 Stanley St, Brisbane, Australia
- Department of Pediatrics, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 8, 3010 Bern, Switzerland
- Department of Paediatrics, Juliana Children’s Hospital/Haga Teaching Hospital, Els Borst-Eilersplein 275, 2545 AA The Hague, The Netherlands
- Section of Pediatrics, Imperial College London, Level 2, Faculty Building South Kensington Campus, London, SW7 2AZ UK
- Translational Pediatrics and Infectious Diseases Section- Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Genetics- Vaccines- Infectious Diseases and Pediatrics research group GENVIP, Health Research Institute of Santiago IDIS/SERGAS, Travesía da Choupana, 15706 Santiago de Compostela, Spain
- Department of General Paediatrics, Medical University of Graz, Auenbruggerplatz 34/2, A-8036 Graz, Austria
- Radboudumc Technology Center Clinical Studies, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Section of Pediatric Infectious Diseases, Laboratory of Medical Immunology, Radboud Institute for Molecular Life Sciences, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases, Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Paediatrics, Faculty of Medicine, Imperial College London, South Kensington Campus, London, SW7 2AZ UK
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, Praed Street, London, W2 1NY UK
- Division of Paediatric Infectious Diseases, Alder Hey Children’s NHS Foundation Trust, Eaton Rd, Liverpool, L12 2AP UK
- Institute of Infection & Global Health, University of Liverpool, 8 West Derby St, Liverpool, L7 3EA UK
- Micropathology Ltd, University of Warwick Science Park, Venture Centre, Sir William Lyons Road, Coventry, CV4 7EZ UK
- Medical research Council Unit, Atlantic Boulevard, Fajara, P. O. Box 273, Banjul, The Gambia
- Department of Paediatric Intensive Care, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- Institute of Cellular Medicine, Newcastle University, 4th Floor, William Leech Building, Framlington Place, Newcastle upon Tyne, NE2 4HH UK
- Division of Infectious Diseases and Hospital Epidemiology, and Children’s Research Center, University Children’s Hospital Zurich, Steinwiesenstrasse 75, 8032 Zurich, Switzerland
- Pediatric Infectious Diseases and Immunology Amalia Children’s Hospital, and Radboudumc Expertise Center for Immunodeficiency and Autoinflammation (REIA), Radboudumc, Geert Grooteplein Zuid 10, 6525 GA Nijmegen, The Netherlands
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN Rotterdam, The Netherlands
- Paediatric Infectious Diseases and Immunology Department, Great North Children’s Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Victoria Wing, Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP UK
- NIHR Newcastle Biomedical Research Centre based at Newcastle upon Tyne Hospitals NHS Trust and Newcastle University, Westgate Rd, Newcastle upon Tyne, NE4 5PL UK
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Baik JS, Seers T, Qureshi S, Nadel S. Shock due to faecal impaction. Arch Dis Child 2018; 103:127. [PMID: 28473310 DOI: 10.1136/archdischild-2017-312672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Ji Soo Baik
- Imperial College Faculty of Medicine, Imperial College London, London, UK
| | - Timothy Seers
- Imperial College Faculty of Medicine, Imperial College London, London, UK
| | - Sabeena Qureshi
- Paediatric Intensive Care Unit, St Mary's Hospital, London, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, London, UK
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38
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Thwaites RS, Jarvis HC, Singh N, Jha A, Pritchard A, Fan H, Tunstall T, Nanan J, Nadel S, Kon OM, Openshaw PJ, Hansel TT. Absorption of Nasal and Bronchial Fluids: Precision Sampling of the Human Respiratory Mucosa and Laboratory Processing of Samples. J Vis Exp 2018. [PMID: 29443104 PMCID: PMC5908664 DOI: 10.3791/56413] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [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] [Indexed: 01/01/2023] Open
Abstract
The methods of nasal absorption (NA) and bronchial absorption (BA) use synthetic absorptive matrices (SAM) to absorb the mucosal lining fluid (MLF) of the human respiratory tract. NA is a non-invasive technique which absorbs fluid from the inferior turbinate, and causes minimal discomfort. NA has yielded reproducible results with the ability to frequently repeat sampling of the upper airway. By comparison, alternative methods of sampling the respiratory mucosa, such as nasopharyngeal aspiration (NPA) and conventional swabbing, are more invasive and may result in greater data variability. Other methods have limitations, for instance, biopsies and bronchial procedures are invasive, sputum contains many dead and dying cells and requires liquefaction, exhaled breath condensate (EBC) contains water and saliva, and lavage samples are dilute and variable. BA can be performed through the working channel of a bronchoscope in clinic. Sampling is well tolerated and can be conducted at multiple sites in the airway. BA results in MLF samples being less dilute than bronchoalveolar lavage (BAL) samples. This article demonstrates the techniques of NA and BA, as well as the laboratory processing of the resulting samples, which can be tailored to the desired downstream biomarker being measured. These absorption techniques are useful alternatives to the conventional sampling techniques used in clinical respiratory research.
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Affiliation(s)
- Ryan S Thwaites
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Hannah C Jarvis
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Nehmat Singh
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Akhilesh Jha
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | | | - Hailing Fan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Tanushree Tunstall
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Joan Nanan
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Simon Nadel
- St Mary's Hospital, Imperial College Healthcare Trust
| | - Onn Min Kon
- St Mary's Hospital, Imperial College Healthcare Trust
| | - Peter J Openshaw
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital
| | - Trevor T Hansel
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, St Mary's Hospital;
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39
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O’Hara CB, Canter RR, Mouncey PR, Carter A, Jones N, Nadel S, Peters MJ, Lyttle MD, Harrison DA, Rowan KM, Inwald D, Woolfall K. A qualitative feasibility study to inform a randomised controlled trial of fluid bolus therapy in septic shock. Arch Dis Child 2018; 103:28-32. [PMID: 28847877 PMCID: PMC5754873 DOI: 10.1136/archdischild-2016-312515] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Revised: 06/01/2017] [Accepted: 06/12/2017] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The Fluids in Shock (FiSh) Trial proposes to evaluate whether restrictive fluid bolus therapy (10 mL/kg) is more beneficial than current recommended practice (20 mL/kg) in the resuscitation of children with septic shock in the UK. This qualitative feasibility study aimed to explore acceptability of the FiSh Trial, including research without prior consent (RWPC), potential barriers to recruitment and participant information for a pilot trial. DESIGN Qualitative interview study involving parents of children who had presented to a UK emergency department or been admitted to a paediatric intensive care unit with severe infection in the previous 3 years. PARTICIPANTS Twenty-one parents (seven bereaved) were interviewed 16 (median) months since their child's hospital admission (range: 1-41). RESULTS All parents said they would have provided consent for the use of their child's data in the FiSh Trial. The majority were unfamiliar with RWPC, yet supported its use. Parents were initially concerned about the change from currently recommended treatment, yet were reassured by explanations of the current evidence base, fluid bolus therapy and monitoring procedures. Parents made recommendations about the timing of the research discussion and content of participant information. Bereaved parents stated that recruiters should not discuss research immediately after a child's death, but supported a personalised postal 'opt-out' approach to consent. CONCLUSIONS Findings show that parents whose child has experienced severe infection supported the proposed FiSh Trial, including the use of RWPC. Parents' views informed the development of the pilot trial protocol and site staff training. TRIAL REGISTRATION NUMBER ISRCTN15244462-results.
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Affiliation(s)
- Caitlin B O’Hara
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Ruth R Canter
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | | | - Nicola Jones
- Patient and Public Involvement Partner, Watford, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mark J Peters
- Institute of Child Health, University College London, UK and Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Mark D Lyttle
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK,Emergency Department, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre (ICNARC), London, UK
| | - David Inwald
- Paediatric Intensive Care Unit, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Kerry Woolfall
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
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40
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Abstract
Infection with the meningococcus is one of the main causes of meningitis and septicaemia worldwide. Humans are the only natural reservoir for the meningococcus which is found primarily as a commensal inhabitant in the nasopharynx in ~10% of adults, and may be found in over 25% of individuals during adolescence. Prompt recognition of meningococcal infection and early aggressive treatment are essential in order to reduce mortality, which occurs in up to 10% of those with invasive meningococcal disease (IMD). This figure may be significantly higher in those with inadequate or delayed treatment. Early administration of effective parenteral antimicrobial therapy and prompt recognition and appropriate management of the complications of IMD, including circulatory shock and raised intracranial pressure (ICP), are critical to help improve patient outcome. This review summarizes clinical features of IMD and current treatment recommendations. We will discuss the evidence for immunization and effects of vaccine strategies, particularly following implementation of effective vaccines against Group B meningococcus.
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Affiliation(s)
- Simon Nadel
- Paediatric Intensive Care Unit, St. Mary's Hospital and Imperial College London, London, United Kingdom
| | - Nelly Ninis
- Paediatrics, St Mary's Hospital, London, United Kingdom
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41
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Thwaites RS, Ito K, Chingono JMS, Coates M, Jarvis HC, Tunstall T, Anderson-Dring L, Cass L, Rapeport G, Openshaw PJ, Nadel S, Hansel TT. Nasosorption as a Minimally Invasive Sampling Procedure: Mucosal Viral Load and Inflammation in Primary RSV Bronchiolitis. J Infect Dis 2017; 215:1240-1244. [PMID: 28368490 PMCID: PMC5441107 DOI: 10.1093/infdis/jix150] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/21/2017] [Indexed: 12/15/2022] Open
Abstract
Background Existing respiratory mucosal sampling methods are flawed, particularly in a pediatric bronchiolitis setting. Methods Twenty-four infants with bronchiolitis were recruited: 12 were respiratory syncytial virus (RSV)-positive, 12 were RSV-negative. Infants were sampled by nasosorption and nasopharyngeal aspiration (NPA). Results Nasosorption was well tolerated and identified all RSV+ samples. RSV load measured by nasosorption (but not NPA) correlated with length of hospital stay (P = .04) and requirement for mechanical ventilation (P = .03). Nasosorption (but not NPA) levels of interferon γ, interleukin 1β, CCL5/RANTES, and interleukin 10 (IL-10) were elevated in RSV+ bronchiolitis (all P < .05), furthermore CCL5 and IL-10 correlated with RSV load (P < .05). Conclusions Nasosorption allowed measurement of RSV load and the mucosal inflammatory response in infants.
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Affiliation(s)
- Ryan S Thwaites
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London
| | | | | | | | - Hannah C Jarvis
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London
| | - Tanushree Tunstall
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London
| | | | | | | | - Peter J Openshaw
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College Healthcare Trust, London, United Kingdom
| | - Trevor T Hansel
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London
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42
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Wedge E, Abrahamson E, Tudor-Williams G, Nadel S, Deal J. When water is thicker than blood: recognising a systemic cause of haemoptysis. Arch Dis Child Educ Pract Ed 2017; 102:210-219. [PMID: 27780827 DOI: 10.1136/archdischild-2015-308957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Revised: 05/27/2016] [Accepted: 09/08/2016] [Indexed: 11/04/2022]
Abstract
The case of an 11-year-old child presenting with acute haemoptysis and breathlessness is described. The girl was Malaysian and had recently arrived in the UK. She subsequently deteriorated, developing respiratory failure. The course of the illness is described, with reference to the diagnostic process at each stage. The case demonstrates the importance of having a broad investigatory approach in acute haemoptysis.
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Affiliation(s)
- Eileen Wedge
- Department of Paediatrics, St Mary's Hospital, London, UK
| | - Ed Abrahamson
- Paediatric Emergency Medicine, Chelsea and Westminster Hospital, London, UK
| | - Gareth Tudor-Williams
- Paediatric Infectious Diseases, Department of Paediatrics, St Mary's Hospital, London, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, Department of Paediatrics, St Mary's Hospital, London, UK
| | - Jane Deal
- Paediatric Renal Medicine, Department of Paediatrics, St Mary's Hospital, London, UK
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43
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Ray S, Rogers L, Noren DP, Dhar R, Nadel S, Peters MJ, Inwald DP. Risk of over-diagnosis of hypotension in children: a comparative analysis of over 50,000 blood pressure measurements. Intensive Care Med 2017; 43:1540-1541. [PMID: 28526952 DOI: 10.1007/s00134-017-4843-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/08/2017] [Indexed: 12/01/2022]
Affiliation(s)
- Samiran Ray
- Respiratory, Critical Care and Anaesthesia Section, UCL GOS Institute of Child Health, 30 Guildford Street, London, WC1N 1EH, UK. .,Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, UK.
| | - Libby Rogers
- UCL Clinical Operations Research Unit, University College London, London, UK
| | - David P Noren
- Philips Research North America, Cambridge, MA, 02141, USA
| | - Ranjana Dhar
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, UK
| | - Simon Nadel
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College London NHS Trust, London, UK
| | - Mark J Peters
- Respiratory, Critical Care and Anaesthesia Section, UCL GOS Institute of Child Health, 30 Guildford Street, London, WC1N 1EH, UK.,Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Trust, London, UK
| | - David P Inwald
- Paediatric Intensive Care Unit, St Mary's Hospital, Imperial College London NHS Trust, London, UK
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44
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Nadel S. A picture paints a thousand words. Acta Paediatr 2017; 106:532-533. [PMID: 28318123 DOI: 10.1111/apa.13733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2016] [Accepted: 12/28/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Simon Nadel
- St Mary's Hospital and Imperial College London, London, UK
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45
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Nadel S, Abboud W, Hassin-Baer S, Arad A, Yahalom R. Ultrasound guided botulinum toxin injections into salivary glands: minimal invasive and safe treatment for drooling. Int J Oral Maxillofac Surg 2017. [DOI: 10.1016/j.ijom.2017.02.831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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46
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O'Hara C, Woolfall K, Canter R, Mouncey P, Rowan K, Lyttle M, Peters M, Inwald D, Nadel S. A QUALITATIVE FEASIBILITY STUDY TO INFORM FLUIDS IN SHOCK (FISH) – A PILOT RANDOMISED CONTROLLED TRIAL OF FLUID BOLUS THERAPY IN SEPTIC SHOCK. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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47
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Martinón-Torres F, Png E, Khor CC, Davila S, Wright VJ, Sim KS, Vega A, Fachal L, Inwald D, Nadel S, Carrol ED, Martinón-Torres N, Alonso SM, Carracedo A, Morteruel E, López-Bayón J, Torre AC, Monge CC, de Aguilar PAG, Torné EE, Martínez-Padilla MDC, Martinón-Sánchez JM, Levin M, Hibberd ML, Salas A. Natural resistance to Meningococcal Disease related to CFH loci: Meta-analysis of genome-wide association studies. Sci Rep 2016; 6:35842. [PMID: 27805046 PMCID: PMC5090968 DOI: 10.1038/srep35842] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [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: 06/07/2016] [Accepted: 10/06/2016] [Indexed: 02/07/2023] Open
Abstract
Meningococcal disease (MD) remains an important infectious cause of life threatening infection in both industrialized and resource poor countries. Genetic factors influence both occurrence and severity of presentation, but the genes responsible are largely unknown. We performed a genome-wide association study (GWAS) examining 5,440,063 SNPs in 422 Spanish MD patients and 910 controls. We then performed a meta-analysis of the Spanish GWAS with GWAS data from the United Kingdom (combined cohorts: 897 cases and 5,613 controls; 4,898,259 SNPs). The meta-analysis identified strong evidence of association (P-value ≤ 5 × 10−8) in 20 variants located at the CFH gene. SNP rs193053835 showed the most significant protective effect (Odds Ratio (OR) = 0.62, 95% confidence interval (C.I.) = 0.52–0.73; P-value = 9.62 × 10−9). Five other variants had been previously reported to be associated with susceptibility to MD, including the missense SNP rs1065489 (OR = 0.64, 95% C.I.) = 0.55–0.76, P-value = 3.25 × 10−8). Theoretical predictions point to a functional effect of rs1065489, which may be directly responsible for protection against MD. Our study confirms the association of CFH with susceptibility to MD and strengthens the importance of this link in understanding pathogenesis of the disease.
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Affiliation(s)
- Federico Martinón-Torres
- Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain, and GENVIP Research Group (www.genvip.org), Instituto de Investigación Sanitaria de Santiago, Galicia, Spain
| | - Eileen Png
- Infectious Diseases, Genome Institute of Singapore, Singapore
| | | | - Sonia Davila
- Human Genetics, Genome Institute of Singapore, Singapore
| | - Victoria J Wright
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, UK
| | - Kar Seng Sim
- Human Genetics, Genome Institute of Singapore, Singapore
| | - Ana Vega
- Fundación Pública Galega de Medicina Xenómica, Servizo Galego de Saúde (SERGAS), Instituto de Investigaciones Sanitarias (IDIS), and Grupo de Medicina Xenómica, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Universidade de Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - Laura Fachal
- Fundación Pública Galega de Medicina Xenómica, Servizo Galego de Saúde (SERGAS), Instituto de Investigaciones Sanitarias (IDIS), and Grupo de Medicina Xenómica, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Universidade de Santiago de Compostela (USC), Santiago de Compostela, Spain
| | - David Inwald
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, UK
| | - Simon Nadel
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, UK
| | - Enitan D Carrol
- Institute of Infection and Global Health, University of Liverpool, Liverpool, UK
| | - Nazareth Martinón-Torres
- Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain, and GENVIP Research Group (www.genvip.org), Instituto de Investigación Sanitaria de Santiago, Galicia, Spain
| | - Sonia Marcos Alonso
- Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain, and GENVIP Research Group (www.genvip.org), Instituto de Investigación Sanitaria de Santiago, Galicia, Spain
| | - Angel Carracedo
- Fundación Pública Galega de Medicina Xenómica, Servizo Galego de Saúde (SERGAS), Instituto de Investigaciones Sanitarias (IDIS), and Grupo de Medicina Xenómica, Centro de Investigación Biomédica en Red de Enfermedades Raras (CIBERER), Universidade de Santiago de Compostela (USC), Santiago de Compostela, Spain.,Unidade de Xenética, Departamento de Anatomía Patolóxica e Ciencias Forenses, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, and GenPop Research Group, Instituto de Investigaciones Sanitarias (IDIS), Hospital Clínico Universitario de Santiago, Galicia, Spain.,Center of Excellence in Genomic Medicine Research, King Abdulaziaz University, Jeddah, Saudi Arabia
| | - Elvira Morteruel
- Unidad de Cuidados Intensivos Pediátricos (UCIP), Hospital de Cruces, Bilbao, Spain
| | - Julio López-Bayón
- Unidad de Cuidados Intensivos Pediátricos (UCIP), Hospital de Cruces, Bilbao, Spain
| | - Andrés Concha Torre
- Unidad de Cuidados Intensivos Pediátricos (UCIP), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | | | | | | | | | - José María Martinón-Sánchez
- Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain, and GENVIP Research Group (www.genvip.org), Instituto de Investigación Sanitaria de Santiago, Galicia, Spain
| | - Michael Levin
- Section of Paediatrics, Division of Infectious Diseases, Department of Medicine, Imperial College London, UK
| | | | - Antonio Salas
- Translational Pediatrics and Infectious Diseases, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain, and GENVIP Research Group (www.genvip.org), Instituto de Investigación Sanitaria de Santiago, Galicia, Spain.,Unidade de Xenética, Departamento de Anatomía Patolóxica e Ciencias Forenses, Instituto de Ciencias Forenses, Facultade de Medicina, Universidade de Santiago de Compostela, and GenPop Research Group, Instituto de Investigaciones Sanitarias (IDIS), Hospital Clínico Universitario de Santiago, Galicia, Spain
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48
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Morin L, Ray S, Wilson C, Remy S, Benissa MR, Jansen NJG, Javouhey E, Peters MJ, Kneyber M, De Luca D, Nadel S, Schlapbach LJ, Maclaren G, Tissieres P. Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition. Intensive Care Med 2016; 42:1948-1957. [PMID: 27709263 PMCID: PMC5106490 DOI: 10.1007/s00134-016-4574-2] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Accepted: 09/22/2016] [Indexed: 12/31/2022]
Abstract
Purpose Although overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal intensive care (ESPNIC) experts’ definition of paediatric RSS. Methods We conducted a two-round Delphi study followed by an observational multicentre retrospective study. One hundred and fourteen paediatric intensivists answered a clinical case-based, two-round Delphi survey, identifying clinical items consistent with RSS. Multivariate analysis of these items in a development single-centre cohort (70 patients, 30 % mortality) facilitated development of RSS definitions based on either a bedside or computed severity score. Both scores were subsequently tested in a validation cohort (six centres, 424 patients, 11.6 % mortality). Results From the Delphi process, the draft definition included evidence of myocardial dysfunction and high blood lactate levels despite high vasopressor treatment. When assessed in the development population, each item was independently associated with the need for extracorporeal life support (ECLS) or death. Resultant bedside and computed septic shock scores had high discriminative power against the need for ECLS or death, with areas under the receiver operating characteristics curve of 0.920 (95 % CI 0.89–0.94), and 0.956 (95 % CI 0.93–0.97), respectively. RSS defined by a bedside score equal to or higher than 2 and a computed score equal to or higher than 3.5 was associated with a significant increase in mortality. Conclusions This ESPNIC definition of RSS accurately identifies children with the most severe form of septic shock. Electronic supplementary material The online version of this article (doi:10.1007/s00134-016-4574-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Luc Morin
- Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Samiran Ray
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Clare Wilson
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Solenn Remy
- Paediatric Intensive Care Unit, Lyon University Hospitals, Bron, France
| | - Mohamed Rida Benissa
- Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France
| | - Nicolaas J G Jansen
- Paediatric Intensive Care Unit, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Etienne Javouhey
- Paediatric Intensive Care Unit, Lyon University Hospitals, Bron, France
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Martin Kneyber
- Paediatric Intensive Care Unit, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands.,Critical care, Anesthesiology, Peri-operative and Emergency medicine (CAPE), The University of Groningen, Groningen, The Netherlands
| | - Daniele De Luca
- Neonatal Intensive Care Unit, Paris South University Hospitals, AP-HP, Clamart, France
| | - Simon Nadel
- Paediatric Intensive Care Unit, Saint-Mary's Hospital, London, UK
| | - Luregn Jan Schlapbach
- Paediatric Intensive Care Unit, Lady Cilento Children's Hospital, Children's Health Queensland, Brisbane, Australia.,Paediatric Critical Care Research Group, Mater Research, The University of Queensland, Brisbane, Australia.,Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Graeme Maclaren
- Department of Paediatrics, Royal Children's Hospital, University of Melbourne, Melbourne, Australia.,Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Pierre Tissieres
- Paediatric Intensive Care Unit, Paris South University Hospitals, AP-HP, 78 Rue du General Leclerc, 94275, Le Kremlin-Bicêtre, France. .,Institute of Integrative Biology of the Cell, Paris Saclay University, Saint-Aubin, France.
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Nadel S, Galliano D, Orozco L. Adoption of environmental management systems and organizational changes: the case of the French industrial firms. Journal of Innovation Economics & Management 2016. [DOI: 10.3917/jie.021.0109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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ESICM LIVES 2016: part three. Intensive Care Med Exp 2016. [PMCID: PMC5042925 DOI: 10.1186/s40635-016-0100-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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